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Inácio Cazeiro D, Azaredo Raposo M, Guimarães T, Lousada N, Jenkins D, R Inácio J, Moreira S, Mineiro A, Freitas C, Martins S, Ferreira R, Luís R, Cardim N, Pinto FJ, Plácido R. Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies. Rev Port Cardiol 2024:S0870-2551(24)00187-2. [PMID: 38945473 DOI: 10.1016/j.repc.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 07/02/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.
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Affiliation(s)
- Daniel Inácio Cazeiro
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Miguel Azaredo Raposo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - David Jenkins
- Cardiothoracic Surgery Department, Royal Papworth Hospital, Cambridge, UK
| | - João R Inácio
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Susana Moreira
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Céline Freitas
- Association for Research and Development of Faculty of Medicine (AIDFM), Cardiovascular Research Support Unit (GAIC), Lisbon, Portugal
| | - Susana Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Ricardo Ferreira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rita Luís
- Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Nuno Cardim
- Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal; Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal.
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Kayali SM, Dietz BE, Siddiq BS, Ghaly M, Owens TS, Khouzam RN. Chronic thromboembolic pulmonary hypertension and balloon pulmonary angioplasty - Where are we in 2024? Curr Probl Cardiol 2024; 49:102481. [PMID: 38401824 DOI: 10.1016/j.cpcardiol.2024.102481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024]
Abstract
Pulmonary endarterectomy (PEA) is the first-line treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients with CTEPH are considered inoperable, and in the last decade, balloon pulmonary angioplasty (BPA) has emerged as a viable therapeutic option for these patients with prohibitive surgical risk or recurrent pulmonary hypertension following PEA. Numerous international centers have increased their procedural volume of BPA and have reported improvements in pulmonary hemodynamics, patient functional class and right ventricular function. Randomized controlled trials have also demonstrated similar findings. Recent refinements in procedural technique, increased operator experience and advancements in procedural technology have facilitated marked reduction in the risk of complications following BPA. Current guidelines recommend BPA for patients with inoperable CTEPH and persistent pulmonary hypertension following PEA. The pulmonary arterial endothelium plays a vital role in the pathophysiologic development and progression of CTEPH.
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Affiliation(s)
- Sharif M Kayali
- University of Tennessee Health Sciences Center, Department of Cardiovascular Medicine, Memphis, TN.
| | - Bernhard E Dietz
- University of Tennessee Health Sciences Center, Department of Internal Medicine, Memphis, TN
| | - Bilal S Siddiq
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Michael Ghaly
- Baptist Memorial Hospital - North Mississippi, Department of Internal Medicine, Oxford, MS
| | - Timothy S Owens
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Rami N Khouzam
- Interventional Cardiologist at the Grand Strand Medical Center, Myrtle Beach, SC; Professor, School of Medicine, University of South Carolina, Columbia SC; Professor, Edward Via College of Osteopathic Medicine, Blacksburg, VA; Professor, at the Mercer School of Medicine, Savannah, GA; Professor, University of Tennessee College of Medicine, Memphis, TN
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Ribas Sola J, Sánchez-Corral Mena MÁ, Riera-Mestre A. [Update in the management of chronic thrombo-embolic pulmonary hypertension]. Med Clin (Barc) 2024; 162:126-133. [PMID: 37925273 DOI: 10.1016/j.medcli.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/06/2023]
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.
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Affiliation(s)
- Jesús Ribas Sola
- Unidad de Enfermedades Vasculares Pulmonares, Servicio de Neumología, Hospital Universitari de Bellvitge, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España.
| | - Miguel Ángel Sánchez-Corral Mena
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España; Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España
| | - Antoni Riera-Mestre
- Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España; Unidad Funcional de ETV, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España.
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Ghani H, Pepke-Zaba J. Chronic Thromboembolic Pulmonary Hypertension: A Review of the Multifaceted Pathobiology. Biomedicines 2023; 12:46. [PMID: 38255153 PMCID: PMC10813488 DOI: 10.3390/biomedicines12010046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic thromboembolic pulmonary disease results from the incomplete resolution of thrombi, leading to fibrotic obstructions. These vascular obstructions and additional microvasculopathy may lead to chronic thromboembolic pulmonary hypertension (CTEPH) with increased pulmonary arterial pressure and pulmonary vascular resistance, which, if left untreated, can lead to right heart failure and death. The pathobiology of CTEPH has been challenging to unravel due to its rarity, possible interference of results with anticoagulation, difficulty in selecting the most relevant study time point in relation to presentation with acute pulmonary embolism (PE), and lack of animal models. In this article, we review the most relevant multifaceted cross-talking pathogenic mechanisms and advances in understanding the pathobiology in CTEPH, as well as its challenges and future direction. There appears to be a genetic background affecting the relevant pathological pathways. This includes genetic associations with dysfibrinogenemia resulting in fibrinolysis resistance, defective angiogenesis affecting thrombus resolution, and inflammatory mediators driving chronic inflammation in CTEPH. However, these are not necessarily specific to CTEPH and some of the pathways are also described in acute PE or deep vein thrombosis. In addition, there is a complex interplay between angiogenic and inflammatory mediators driving thrombus non-resolution, endothelial dysfunction, and vascular remodeling. Furthermore, there are data to suggest that infection, the microbiome, circulating microparticles, and the plasma metabolome are contributing to the pathobiology of CTEPH.
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Affiliation(s)
- Hakim Ghani
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge CB2 0AY, UK;
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Ramanan R, McFadyen JD, Perkins AC, Tran HA. Congenital fibrinogen disorders: Strengthening genotype-phenotype correlations through novel genetic diagnostic tools. Br J Haematol 2023; 203:355-368. [PMID: 37583269 DOI: 10.1111/bjh.19039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/29/2023] [Accepted: 08/02/2023] [Indexed: 08/17/2023]
Abstract
Congenital fibrinogen disorders or CFDs are heterogenous, both in clinical manifestation and array of culprit molecular lesions. Correlations between phenotype and genotype remain poorly defined. This review examines the genetic landscape discovered to date for this rare condition. The question of a possible oligogenic model of inheritance influencing phenotypic heterogeneity is raised, with discussion of the benefits and challenges of sequencing technology used to enhance discovery in this space. Considerable work lies ahead in order to achieve diagnostic and prognostic precision and subsequently provide targeted management to this complex cohort of patients.
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Affiliation(s)
- Radha Ramanan
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Department of Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - James D McFadyen
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Atherothrombosis and Vascular Biology Program, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Andrew C Perkins
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
- Department of Pathology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Huyen A Tran
- Department of Haematology, Alfred Hospital, Melbourne, Victoria, Australia
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
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Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
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Swisher JW, Weaver E. The Evolving Management and Treatment Options for Patients with Pulmonary Hypertension: Current Evidence and Challenges. Vasc Health Risk Manag 2023; 19:103-126. [PMID: 36895278 PMCID: PMC9990521 DOI: 10.2147/vhrm.s321025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/01/2023] [Indexed: 03/06/2023] Open
Abstract
Pulmonary hypertension may develop as a disease process specific to pulmonary arteries with no identifiable cause or may occur in relation to other cardiopulmonary and systemic illnesses. The World Health Organization (WHO) classifies pulmonary hypertensive diseases on the basis of primary mechanisms causing increased pulmonary vascular resistance. Effective management of pulmonary hypertension begins with accurately diagnosing and classifying the disease in order to determine appropriate treatment. Pulmonary arterial hypertension (PAH) is a particularly challenging form of pulmonary hypertension as it involves a progressive, hyperproliferative arterial process that leads to right heart failure and death if untreated. Over the last two decades, our understanding of the pathobiology and genetics behind PAH has evolved and led to the development of several targeted disease modifiers that ameliorate hemodynamics and quality of life. Effective risk management strategies and more aggressive treatment protocols have also allowed better outcomes for patients with PAH. For those patients who experience progressive PAH with medical therapy, lung transplantation remains a life-saving option. More recent work has been directed at developing effective treatment strategies for other forms of pulmonary hypertension, such as chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary hypertension due to other lung or heart diseases. The discovery of new disease pathways and modifiers affecting the pulmonary circulation is an ongoing area of intense investigation.
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Affiliation(s)
- John W Swisher
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
| | - Eric Weaver
- East Tennessee Pulmonary Hypertension Center, StatCare Pulmonary Consultants, Knoxville, TN, USA
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Myllylahti L, Ropponen J, Lax M, Lassila R, Nykänen AI. Upregulation of Coagulation Factor VIII and Fibrinogen After Pulmonary Endarterectomy in Patients with Chronic Thromboembolic Pulmonary Hypertension. Clin Appl Thromb Hemost 2023; 29:10760296231158369. [PMID: 36890726 PMCID: PMC9998419 DOI: 10.1177/10760296231158369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2023] Open
Abstract
OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with thrombotic states including elevated coagulation factor VIII (FVIII). Pulmonary endarterectomy (PEA) is the main treatment for CTEPH, and efficient anticoagulation is essential to prevent thromboembolism recurrence after surgery. We aimed to characterize longitudinal changes in FVIII and other coagulation biomarkers after PEA. METHODS Coagulation biomarker levels were measured at baseline and up to 12 months after operation in 17 consecutive patients with PEA. Temporal patterns of coagulation biomarkers, and correlation of FVIII with other coagulation biomarkers, were analyzed. RESULTS Baseline FVIII levels were elevated in 71% of the patients (mean 216 ± 67 IU/dl). FVIII doubled 7 days after PEA, peaking at 471 ± 87 IU/dl, and gradually returned to respective baseline levels within 3 months. Postoperative fibrinogen levels were also elevated. Antithrombin decreased at 1 to 3 days, D-dimer increased at 1 to 4 weeks, and thrombocytosis was observed at 2 weeks. CONCLUSIONS FVIII is elevated in most patients with CTEPH. After PEA, early but transient elevation of FVIII and fibrinogen, and delayed reactive thrombocytosis, occurs, and warrants careful postoperative anticoagulation to prevent thromboembolism recurrence.
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Affiliation(s)
- Lasse Myllylahti
- Division of Internal Medicine, Department of Internal Medicine and Rehabilitation, Helsinki University Hospital, Helsinki, Finland
| | - Jussi Ropponen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Mikko Lax
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital, Helsinki, Finland
| | - Riitta Lassila
- Unit of Coagulation Disorders, Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital, and Research Program Unit in Systems Oncology, 3835University of Helsinki, Helsinki, Finland
| | - Antti I Nykänen
- Department of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Wolberg AS, Sang Y. Fibrinogen and Factor XIII in Venous Thrombosis and Thrombus Stability. Arterioscler Thromb Vasc Biol 2022; 42:931-941. [PMID: 35652333 PMCID: PMC9339521 DOI: 10.1161/atvbaha.122.317164] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
As the third most common vascular disease, venous thromboembolism is associated with significant mortality and morbidity. Pathogenesis underlying venous thrombosis is still not fully understood. Accumulating data suggest fibrin network structure and factor XIII-mediated crosslinking are major determinants of venous thrombus mass, composition, and stability. Understanding the cellular and molecular mechanisms mediating fibrin(ogen) and factor XIII production and function and their ability to influence venous thrombogenesis and resolution may inspire new anticoagulant strategies that target these proteins to reduce or prevent venous thrombosis in certain at-risk patients. This article summarizes fibrinogen and factor XIII biology and current knowledge of their function during venous thromboembolism.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
| | - Yaqiu Sang
- Department of Pathology and UNC Blood Research Center, University of North Carolina, Chapel Hill
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Lian TY, Liu JZ, Guo F, Zhou YP, Wu T, Wang H, Li JY, Yan XX, Peng FH, Sun K, Xu XQ, Han ZY, Jiang X, Wang DL, Miao Q, Jing ZC. Prevalence, Genetic Background, and Clinical Phenotype of Congenital Thrombophilia in Chronic Thromboembolic Pulmonary Hypertension. JACC: ASIA 2022; 2:247-255. [PMID: 36338413 PMCID: PMC9627833 DOI: 10.1016/j.jacasi.2022.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/20/2022] [Accepted: 02/24/2022] [Indexed: 01/22/2023]
Abstract
Background The role of congenital thrombophilia in chronic thromboembolic pulmonary hypertension (CTEPH) remains unresolved. Objectives The purpose of this study was to investigate the prevalence, genetic background, and clinical phenotype of congenital thrombophilia in CTEPH. Methods In total, 367 patients with CTEPH from May 2013 to December 2020 were consecutively enrolled in this cross-sectional study in FuWai Hospital and Peking Union Medical College Hospital in China. The primary outcome was the occurrence of congenital thrombophilia diagnosed through tests for congenital anticoagulants activity (including protein C, protein S, and antithrombin III), factor V Leiden and prothrombin G20210A sequence variants. Next-generation sequencing was conducted for patients with congenital thrombophilia. Clinical phenotype was compared between patients with and without thrombophilia. Results A total of 36 (9.8%; 95% CI: 6.8%-12.9%) patients were diagnosed as congenital thrombophilia, including 13 protein C deficiency (3.5%; 95% CI: 1.6%-5.4%), 19 protein S deficiency (5.2%; 95% CI: 2.9%-7.5%), and 4 antithrombin III deficiency (1.1%; 95% CI: 0%-2.2%). No factor V Leiden or prothrombin G20210A sequence variants were identified. Genotype for patients with thrombophilia revealed that 10 (76.9%) protein C deficiency patients were PROC sequence variant carriers, 4 (21.1%) protein S deficiency were PROS1 sequence variant carriers, and 2 (50.0%) antithrombin III deficiency were SERPINC1 sequence variant carriers. In the logistic regression model, male sex (OR: 3.24; 95% CI: 1.43-7.31) and proximal lesion in pulmonary arteries (OR: 4.10; 95% CI: 1.91-8.85) had significant differences between the congenital thrombophilia and nonthrombophilia group in CTEPH patients. Conclusions Congenital thrombophilia was not rare. Male sex and proximal lesion in pulmonary arteries might be the specific clinical phenotype for CTEPH patients with congenital thrombophilia.
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Affiliation(s)
- Tian-Yu Lian
- Medical Science Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian-Zhou Liu
- Department of Cardiovascular Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fan Guo
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Wu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Hui Wang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing-Yi Li
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, FuWai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Hua Peng
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, FuWai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Medical Science Research Center, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Yan Han
- Department of Anesthesiology, FuWai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Duo-Lao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Qi Miao
- Department of Cardiovascular Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Dr Qi Miao, Department of Cardiovascular Surgery, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing 100730, China
| | - Zhi-Cheng Jing
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Address for correspondence: Prof Zhi-Cheng Jing, Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing 100730, China. @Jing_ZhiCheng
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Chronic Thromboembolic Pulmonary Hypertension. Lung 2022; 200:283-299. [DOI: 10.1007/s00408-022-00539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/18/2022] [Indexed: 10/18/2022]
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Laggner M, Oberndorfer F, Golabi B, Bauer J, Zuckermann A, Hacker P, Lang I, Skoro-Sajer N, Gerges C, Taghavi S, Jaksch P, Mildner M, Ankersmit HJ, Moser B. EGR1 Is Implicated in Right Ventricular Cardiac Remodeling Associated with Pulmonary Hypertension. BIOLOGY 2022; 11:biology11050677. [PMID: 35625405 PMCID: PMC9138384 DOI: 10.3390/biology11050677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/16/2022]
Abstract
Background: Pulmonary hypertension (PH) is a vasoconstrictive disease characterized by elevated mean pulmonary arterial pressure (mPAP) at rest. Idiopathic pulmonary arterial hypertension (iPAH) and chronic thromboembolic pulmonary hypertension (CTEPH) represent two distinct subtypes of PH. Persisting PH leads to right ventricular (RV) hypertrophy, heart failure, and death. RV performance predicts survival and surgical interventions re-establishing physiological mPAP reverse cardiac remodeling. Nonetheless, a considerable number of PH patients are deemed inoperable. The underlying mechanism(s) governing cardiac regeneration, however, remain largely elusive. Methods: In a longitudinal approach, we profiled the transcriptional landscapes of hypertrophic RVs and recovered hearts 3 months after surgery of iPAH and CTEPH patients. Results: Genes associated with cellular responses to inflammatory stimuli and metal ions were downregulated, and cardiac muscle tissue development was induced in iPAH after recovery. In CTEPH patients, genes related to muscle cell development were decreased, and genes governing cardiac conduction were upregulated in RVs following regeneration. Intriguingly, early growth response 1 (EGR1), a profibrotic regulator, was identified as a major transcription factor of hypertrophic RVs in iPAH and CTEPH. A histological assessment confirmed our biocomputational results, and suggested a pivotal role for EGR1 in RV vasculopathy. Conclusion: Our findings improved our understanding of the molecular events driving reverse cardiac remodeling following surgery. EGR1 might represent a promising candidate for targeted therapy of PH patients not eligible for surgical treatment.
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Affiliation(s)
- Maria Laggner
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
- Applied Immunology Laboratory, Medical University of Vienna, 1090 Vienna, Austria
| | - Felicitas Oberndorfer
- Clinical Institute of Pathology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Bahar Golabi
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria; (B.G.); (M.M.)
| | - Jonas Bauer
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
| | - Andreas Zuckermann
- Department of Cardiology, Medical University of Vienna, 1090 Vienna, Austria;
| | - Philipp Hacker
- Department of Oral and Maxillofacial Surgery, University Hospital St. Poelten, 3100 St. Poelten, Austria;
| | - Irene Lang
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (I.L.); (N.S.-S.); (C.G.)
| | - Nika Skoro-Sajer
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (I.L.); (N.S.-S.); (C.G.)
| | - Christian Gerges
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, 1090 Vienna, Austria; (I.L.); (N.S.-S.); (C.G.)
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
| | - Peter Jaksch
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
| | - Michael Mildner
- Department of Dermatology, Medical University of Vienna, 1090 Vienna, Austria; (B.G.); (M.M.)
| | - Hendrik Jan Ankersmit
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
- Applied Immunology Laboratory, Medical University of Vienna, 1090 Vienna, Austria
| | - Bernhard Moser
- Department of Thoracic Surgery, Medical University of Vienna, 1090 Vienna, Austria; (M.L.); (J.B.); (S.T.); (P.J.); (H.J.A.)
- Correspondence:
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13
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Kattula S, Sang Y, de Ridder G, Silver AC, Bouck EG, Cooley BC, Wolberg AS. Novel venous thromboembolism mouse model to evaluate the role of complete and partial factor XIII deficiency in pulmonary embolism risk. J Thromb Haemost 2021; 19:2997-3007. [PMID: 34431201 PMCID: PMC8605765 DOI: 10.1111/jth.15510] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/19/2021] [Accepted: 08/23/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thrombosis (VT) and pulmonary embolism (PE), collectively venous thromboembolism (VTE), cause high mortality and morbidity. Factor XIII (FXIII) crosslinks fibrin to enhance thrombus stability and consequently may influence PE risk. Elucidating mechanisms contributing to PE is limited by a lack of models that recapitulate human PE characteristics. OBJECTIVE We aimed to develop a mouse model that permits embolization of red blood cell (RBC)- and fibrin-rich VT and determine the contribution of FXIII to PE risk. METHODS AND RESULTS In a thrombin-infusion PE model, F13a+/+ , F13a+/- , and F13a-/- mice had similar incidence of microthrombi in the lungs; however, thrombi were small, with low RBC content (≤7%), unlike human PEs (~70%). To identify a model producing PE consistent with histological characteristics of human PE, we compared mouse femoral vein electrolytic injury, femoral vein FeCl3 injury, and infrarenal vena cava (IVC) stasis models of VT. Electrolytic and FeCl3 models produced small thrombi with few RBCs (5% and 4%, respectively), whereas IVC stasis produced large thrombi with higher RBC content (68%) that was similar to human PEs. After IVC stasis and ligature removal (de-ligation) to permit thrombus embolization, compared to F13a+/+ mice, F13a+/- and F13a-/- mice had similar and increased PE incidence, respectively. CONCLUSIONS Compared to thrombin infusion-, electrolytic injury-, and FeCl3 -based models, IVC stasis produces thrombi that are more histologically similar to human thrombi. IVC stasis followed by de-ligation permits embolization of existing RBC- and fibrin-rich thrombi. Complete FXIII deficiency increases PE incidence, but partial deficiency does not.
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Affiliation(s)
- Sravya Kattula
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Yaqiu Sang
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Gustaaf de Ridder
- Department of Pathology and Laboratory Medicine, Transfusion Medicine, University of North Carolina at Chapel Hill, USA
| | - Anna C. Silver
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Brian C. Cooley
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina at Chapel Hill, USA
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14
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D’Andrea G, Margaglione M. Rare Defects: Looking at the Dark Face of the Thrombosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18179146. [PMID: 34501736 PMCID: PMC8430787 DOI: 10.3390/ijerph18179146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 12/16/2022]
Abstract
Venous thromboembolism (VTE) constitutes a serious and potentially fatal disease, often complicated by pulmonary embolism and is associated with inherited or acquired factors risk. A series of risk factors are known to predispose to venous thrombosis, and these include mutations in the genes that encode anticoagulant proteins as antithrombin, protein C and protein S, and variants in genes that encode instead pro-coagulant factors as factor V (FV Leiden) and factor II (FII G20210A). However, the molecular causes responsible for thrombotic events in some individuals with evident inherited thrombosis remain unknown. An improved knowledge of risk factors, as well as a clear understanding of their role in the pathophysiology of VTE, are crucial to achieve a better identification of patients at higher risk. Moreover, the identification of genes with rare variants but a large effect size may pave the way for studies addressing new antithrombotic agents in order to improve the management of VTE patients. Over the past 20 years, qualitative or quantitative genetic risk factors such as inhibitor proteins of the hemostasis and of the fibrinolytic system, including fibrinogen, thrombomodulin, plasminogen activator inhibitor-1, and elevated concentrations of factors II, FV, VIII, IX, XI, have been associated with thrombotic events, often with conflicting results. The aim of this review is to evaluate available data in literature on these genetic variations to give a contribution to our understanding of the complex molecular mechanisms involved in physiologic and pathophysiologic clot formation and their role in clinical practice.
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15
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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16
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Cao Y, Geng C, Li Y, Zhang Y. In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease. Front Pharmacol 2021; 12:671589. [PMID: 34305592 PMCID: PMC8296465 DOI: 10.3389/fphar.2021.671589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.
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Affiliation(s)
- Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chao Geng
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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17
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Chausheva S, Redwan B, Sharma S, Marella N, Schossleitner K, Mueller AC, Petzelbauer P, Morris T, Lang IM. Synthetic Fibrin-Derived Bβ 15-42 Peptide Delays Thrombus Resolution in a Mouse Model. Arterioscler Thromb Vasc Biol 2021; 41:2168-2180. [PMID: 34078093 DOI: 10.1161/atvbaha.121.316404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Stella Chausheva
- Division of Cardiology, Department of Internal Medicine II (S.C., S.S., I.M.L.), Medical University of Vienna, Austria
| | - Bassam Redwan
- Department of Thoracic Surgery, Klinik am Park, Klinikum Westfalen, Luenen, Germany (B.R.)
| | - Smriti Sharma
- Division of Cardiology, Department of Internal Medicine II (S.C., S.S., I.M.L.), Medical University of Vienna, Austria
| | - Nara Marella
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Austria (N.M., A.C.M.)
| | - Klaudia Schossleitner
- Skin and Endothelial Research Division, Department of Dermatology (K.S., P.P.), Medical University of Vienna, Austria
| | - André C Mueller
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Austria (N.M., A.C.M.)
| | - Peter Petzelbauer
- Skin and Endothelial Research Division, Department of Dermatology (K.S., P.P.), Medical University of Vienna, Austria
| | - Timothy Morris
- Division of Pulmonary and Critical Care Medicine, University of California San Diego (T.M.)
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II (S.C., S.S., I.M.L.), Medical University of Vienna, Austria
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18
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Abstract
Fibrinolysis is of paramount importance in maintaining or regaining the patency of veins and pulmonary arteries obstructed by thrombi. Growing experimental and clinical evidence indicates that impaired fibrinolysis mediated by multiple complex mechanisms is involved in venous thromboembolism (VTE). Global plasma fibrin clot lysis markers, especially clot lysis time, have been reported to predict recurrent deep-vein thrombosis and pulmonary embolism. The current overview summarizes available data linking fibrinolysis to VTE and its long-term sequelae.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,Krakow Centre for Medical Research and Technologies, John Paul II Hospital, Krakow, Poland
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19
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Right ventricular echocardiographic parameters associated with prothrombotic abnormalities in normotensive patients with acute pulmonary embolism. Int J Cardiol 2021; 333:195-201. [PMID: 33676943 DOI: 10.1016/j.ijcard.2021.02.087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 02/15/2021] [Accepted: 02/26/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND In acute pulmonary embolism (PE) right ventricular (RV) pressure overload negatively affects prognosis. Recently we have shown that RV dilatation is associated with a prothrombotic state in PE. We investigated which RV echocardiographic parameters best indicate prothrombotic alterations in acute PE. METHODS In 121 normotensive, noncancer PE patients, markers of RV dilatation and dysfunction were evaluated on admission using transthoracic echocardiography, along with prothrombotic state markers, i.e. increased endogenous thrombin generation (ETP), low fibrin clot permeability (Ks, a measure of clot density), and prolonged clot lysis time (CLT). RESULTS RV parasternal long axis (RVOT PLAX) >30 mm was associated with ETP (OR 3.86; 95% CI 1.55-9.62; p = 0.004) and CLT (OR 4.08; 95% CI 1.58-10.54; p = 0.004) in the top quartiles, but not with Ks. RV short parasternal axis (RVOT PSAX) >27 mm showed similar associations with higher ETP (OR 3.54; 95% CI 1.50-8.37; p = 0.004) and prolonged CLT (OR 2.78; 95% CI 1.17-6.62; p = 0.021). RV basal diameter >41 mm solely predicted prolonged CLT (OR 2.93; 95% CI 1.23-6.99; p = 0.016). The right atrium area, pulmonary trunk diameter, and tricuspid regurgitation maximum velocity were not related to prothrombotic markers, except for tricuspid annular plane systolic excursion weakly associated with ETP. Multivariable analysis showed that RVOT PSAX is independently associated with prolonged CLT (OR 1.16; 95% CI 1.04-1.30; p = 0.007), low Ks (OR 1.21; 95% CI 1.02-1.44; p = 0.029), and higher ETP (OR 1.14; 95% CI 1.03-1.26; p = 0.009). CONCLUSIONS Among RV echocardiographic parameters, the RVOT dilatation measured in PSAX best predicts prothrombotic alterations in PE patients.
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20
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Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
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Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
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21
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Schwabkey ZI, Sheehan FC, Bellomo C, Raval M. Congenital dysfibrinogenaemia presented with preterm premature rupture of the membranes and vaginal bleeding. BMJ Case Rep 2020; 13:13/9/e235961. [PMID: 32948529 DOI: 10.1136/bcr-2020-235961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 26-year-old woman was found to have congenital dysfibrinogenaemia after presenting to our hospital with premature rupture of the membranes and vaginal bleeding. Given the absence of clear guidelines for the management of pregnancy complicated by dysfibrinogenaemia, we followed expert consensus that exists among published works, with some modifications. This case was managed by a multidisciplinary team of obstetrics-gynaecology, haematology and paediatric haematology. Here we review how the patient presented, the investigations that led to the diagnosis and the treatment options.
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Affiliation(s)
- Zaker I Schwabkey
- Department of Internal Medicine, Albany Medical College, Albany, New York, USA
| | - Farrell C Sheehan
- Department of Internal Medicine, Albany Medical College, Albany, New York, USA
| | - Courtney Bellomo
- Department of Internal Medicine, Albany Medical College, Albany, New York, USA.,New York Oncology Hematology PC, Albany, New York, USA
| | - Mihir Raval
- Department of Internal Medicine, Albany Medical College, Albany, New York, USA.,New York Oncology Hematology PC, Albany, New York, USA
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22
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Yan L, Li X, Liu Z, Zhao Z, Luo Q, Zhao Q, Jin Q, Yu X, Zhang Y. Research progress on the pathogenesis of CTEPH. Heart Fail Rev 2020; 24:1031-1040. [PMID: 31087212 DOI: 10.1007/s10741-019-09802-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an established long-term complication of pulmonary thromboembolism (PTE). However, studies have shown that many patients with a definitive CTEPH diagnosis have no history of symptomatic PTE, suggesting that PTE is not the only cause of CTEPH. Despite extensive progress in research on pulmonary hypertension in recent years, due to a lack of relevant studies on the pathophysiology of CTEPH, implementing pulmonary endarterectomy (PEA) in patients has many challenges, and the prognosis of patients with CTEPH is still not optimistic. Therefore, revealing the pathogenesis of CTEPH would be of great significance for understanding the occurrence and development of CTEPH, developing relevant drug treatment studies and formulating intervention strategies, and may provide new preventive measures. This article summarizes the current research progress in CTEPH pathogenesis from the perspective of risk factors related to medical history, abnormal coagulation and fibrinolytic mechanisms, inflammatory mechanisms, genetic susceptibility factors, angiogenesis, in situ thrombosis, vascular remodeling, and other aspects.
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Affiliation(s)
- Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China.
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xue Yu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
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Eichstaedt CA, Verweyen J, Halank M, Benjamin N, Fischer C, Mayer E, Guth S, Wiedenroth CB, Egenlauf B, Harutyunova S, Xanthouli P, Marra AM, Wilkens H, Ewert R, Hinderhofer K, Grünig E. Myeloproliferative Diseases as Possible Risk Factor for Development of Chronic Thromboembolic Pulmonary Hypertension-A Genetic Study. Int J Mol Sci 2020; 21:ijms21093339. [PMID: 32397294 PMCID: PMC7246715 DOI: 10.3390/ijms21093339] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 04/30/2020] [Accepted: 05/06/2020] [Indexed: 11/16/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease which is often caused by recurrent emboli. These are also frequently found in patients with myeloproliferative diseases. While myeloproliferative diseases can be caused by gene defects, the genetic predisposition to CTEPH is largely unexplored. Therefore, the objective of this study was to analyse these genes and further genes involved in pulmonary hypertension in CTEPH patients. A systematic screening was conducted for pathogenic variants using a gene panel based on next generation sequencing. CTEPH was diagnosed according to current guidelines. In this study, out of 40 CTEPH patients 4 (10%) carried pathogenic variants. One patient had a nonsense variant (c.2071A>T p.Lys691*) in the BMPR2 gene and three further patients carried the same pathogenic variant (missense variant, c.1849G>T p.Val617Phe) in the Janus kinase 2 (JAK2) gene. The latter led to a myeloproliferative disease in each patient. The prevalence of this JAK2 variant was significantly higher than expected (p < 0.0001). CTEPH patients may have a genetic predisposition more often than previously thought. The predisposition for myeloproliferative diseases could be an additional risk factor for CTEPH development. Thus, clinical screening for myeloproliferative diseases and genetic testing may be considered also for CTEPH patients.
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Affiliation(s)
- Christina A. Eichstaedt
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
- Correspondence: ; Tel.: +49-6221-396-1221; Fax: +49-6221-396-1222
| | - Jeremias Verweyen
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Michael Halank
- Department of Internal Medicine I, Carl Gustav Carus University Hospital, Technical University of Dresden, Fetscherstraße 74, 01307 Dresden, Germany;
| | - Nicola Benjamin
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Christine Fischer
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Christoph B. Wiedenroth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Benekestr. 2–8, 61231 Bad Nauheim, Germany; (S.G.); (C.B.W.); (E.M.)
| | - Benjamin Egenlauf
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Satenik Harutyunova
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Panagiota Xanthouli
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
| | - Alberto M. Marra
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
- IRCCS SDN Research Institute, Via F. Crispi 8, 80121 Naples, Italy
| | - Heinrike Wilkens
- Department of Internal Medicine V—Pneumology, Allergology and Critical Care Medicine, University Hospital of Saarland, Kirrberger Str., 66424 Homburg, Saar, Germany;
| | - Ralf Ewert
- Department of Internal Medicine B—Cardiology, Intensive Care, Pulmonary Medicine and Infectious Diseases, University of Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany;
| | - Katrin Hinderhofer
- Laboratory of Molecular Genetic Diagnostics, Institute of Human Genetics, Heidelberg University, Im Neuenheimer Feld 366, 69120 Heidelberg, Germany; (C.F.); (K.H.)
| | - Ekkehard Grünig
- Centre for Pulmonary Hypertension, Thoraxklinik Heidelberg gGmbH, Heidelberg University Hospital, Röntgenstr. 1, 69126 Heidelberg, Germany; (J.V.); (N.B.); (B.E.); (S.H.); (P.X.); (A.M.M.); (E.G.)
- Translational Lung Research Centre (TLRC), German Centre for Lung Research (DZL), Im Neuenheimer Feld 156, 69120 Heidelberg, Germany
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Halliday SJ, Matthews DT, Talati MH, Austin ED, Su YR, Absi TS, Fortune NL, Gailani D, Matafonov A, West JD, Hemnes AR. A multifaceted investigation into molecular associations of chronic thromboembolic pulmonary hypertension pathogenesis. JRSM Cardiovasc Dis 2020; 9:2048004020906994. [PMID: 32110389 PMCID: PMC7019411 DOI: 10.1177/2048004020906994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose Chronic thromboembolic pulmonary hypertension is characterized by incomplete
thrombus resolution following acute pulmonary embolism, leading to pulmonary
hypertension and right ventricular dysfunction. Conditions such as
thrombophilias, dysfibrinogenemias, and inflammatory states have been
associated with chronic thromboembolic pulmonary hypertension, but molecular
mechanisms underlying this disease are poorly understood. We sought to
characterize the molecular and functional features associated with chronic
thromboembolic pulmonary hypertension using a multifaceted approach. Methods We utilized functional assays to compare clot lysis times between chronic
thromboembolic pulmonary hypertension patients and multiple controls. We
then performed immunohistochemical characterization of tissue from chronic
thromboembolic pulmonary hypertension, pulmonary arterial hypertension, and
healthy controls, and examined RNA expression patterns of cultured
lymphocytes and pulmonary arterial specimens. We then confirmed RNA
expression changes using immunohistochemistry, immunofluorescence, and
Western blotting in pulmonary arterial tissue. Results Clot lysis times in chronic thromboembolic pulmonary hypertension patients
are similar to multiple controls. Chronic thromboembolic pulmonary
hypertension endarterectomized tissue has reduced expression of both smooth
muscle and endothelial cell markers. RNA expression profiles in pulmonary
arteries and peripheral blood lymphocytes identified differences in RNA
transcript levels related to inflammation and growth factor signaling, which
we confirmed using immunohistochemistry. Gene expression data also suggested
significant alterations in metabolic pathways, and immunofluorescence and
Western blot experiments confirmed that unglycosylated CD36 and adiponectin
expression were increased in chronic thromboembolic pulmonary hypertension
versus controls. Conclusions Our data do not support impaired clot lysis underlying chronic thromboembolic
pulmonary hypertension, but did demonstrate distinct molecular patterns
present both in peripheral blood and in pathologic specimens of chronic
thromboembolic pulmonary hypertension patients suggesting that altered
metabolism may play a role in chronic thromboembolic pulmonary hypertension
pathogenesis.
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Affiliation(s)
- Stephen J Halliday
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin Madison, Madison, USA
| | - Daniel T Matthews
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Megha H Talati
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Eric D Austin
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Yan R Su
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Niki L Fortune
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - James D West
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
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25
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Vilar R, Fish RJ, Casini A, Neerman-Arbez M. Fibrin(ogen) in human disease: both friend and foe. Haematologica 2020; 105:284-296. [PMID: 31949010 PMCID: PMC7012490 DOI: 10.3324/haematol.2019.236901] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/21/2019] [Indexed: 12/19/2022] Open
Abstract
Fibrinogen is an abundant protein synthesized in the liver, present in human blood plasma at concentrations ranging from 1.5-4 g/L in healthy individuals with a normal half-life of 3-5 days. With fibrin, produced by thrombin-mediated cleavage, fibrinogen plays important roles in many physiological processes. Indeed, the formation of a stable blood clot, containing polymerized and cross-linked fibrin, is crucial to prevent blood loss and drive wound healing upon vascular injury. A balance between clotting, notably the conversion of fibrinogen to fibrin, and fibrinolysis, the proteolytic degradation of the fibrin mesh, is essential. Disruption of this equilibrium can cause disease in distinct manners. While some pathological conditions are the consequence of altered levels of fibrinogen, others are related to structural properties of the molecule. The source of fibrinogen expression and the localization of fibrin(ogen) protein also have clinical implications. Low levels of fibrinogen expression have been detected in extra-hepatic tissues, including carcinomas, potentially contributing to disease. Fibrin(ogen) deposits at aberrant sites including the central nervous system or kidney, can also be pathological. In this review, we discuss disorders in which fibrinogen and fibrin are implicated, highlighting mechanisms that may contribute to disease.
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Affiliation(s)
- Rui Vilar
- Department of Genetic Medicine and Development, University of Geneva Faculty of Medicine
| | - Richard J Fish
- Department of Genetic Medicine and Development, University of Geneva Faculty of Medicine
| | - Alessandro Casini
- Division of Angiology and Hemostasis, University Hospitals and University of Geneva Faculty of Medicine
| | - Marguerite Neerman-Arbez
- Department of Genetic Medicine and Development, University of Geneva Faculty of Medicine .,iGE3, Institute of Genetics and Genomics in Geneva, Geneva, Switzerland
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26
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Missing regions within the molecular architecture of human fibrin clots structurally resolved by XL-MS and integrative structural modeling. Proc Natl Acad Sci U S A 2020; 117:1976-1987. [PMID: 31924745 PMCID: PMC6995014 DOI: 10.1073/pnas.1911785117] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Fibrinogen hexamers are major components of blood clots. After release of fibrinopeptides resulting in fibrin monomers, clot formation occurs through fibrin oligomerization followed by lateral aggregation, packing into fibrin fibers, and consequent branching. Shedding light on fibrin clots by in situ cross-linking mass spectrometry and structural modeling extends our current knowledge of the structure of fibrin with regard to receptor-binding hotspots. Further restraint-driven molecular docking reveals how fibrin oligomers laterally aggregate into clots and uncovers the molecular architecture of the clot to albumin interaction. We hypothesize this interaction is involved in the prevention of clot degradation. Mapping known mutations validates the generated structural model and, for a subset, brings their molecular mechanisms into view. Upon activation, fibrinogen forms large fibrin biopolymers that coalesce into clots which assist in wound healing. Limited insights into their molecular architecture, due to the sheer size and the insoluble character of fibrin clots, have restricted our ability to develop novel treatments for clotting diseases. The, so far resolved, disparate structural details have provided insights into linear elongation; however, molecular details like the C-terminal domain of the α-chain, the heparin-binding domain on the β-chain, and other functional domains remain elusive. To illuminate these dark areas, we applied cross-linking mass spectrometry (XL-MS) to obtain biochemical evidence in the form of over 300 distance constraints and combined this with structural modeling. These restraints additionally define the interaction network of the clots and provide molecular details for the interaction with human serum albumin (HSA). We were able to construct the structural models of the fibrinogen α-chain (excluding two highly flexible regions) and the N termini of the β-chain, confirm these models with known structural arrangements, and map how the structure laterally aggregates to form intricate lattices together with the γ-chain. We validate the final model by mapping mutations leading to impaired clot formation. From a list of 22 mutations, we uncovered structural features for all, including a crucial role for βArg’169 (UniProt: 196) in lateral aggregation. The resulting model can potentially serve for research on dysfibrinogenemia and amyloidosis as it provides insights into the molecular mechanisms of thrombosis and bleeding disorders related to fibrinogen variants. The structure is provided in the PDB-DEV repository (PDBDEV_00000030).
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27
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Ranka S, Mohananey D, Agarwal N, Verma BR, Villablanca P, Mewhort HE, Ramakrishna H. Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:2513-2523. [PMID: 31883688 DOI: 10.1053/j.jvca.2019.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, Kansas University Medical Center, Kansas City, KS
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Nikhil Agarwal
- Division of Cardiovascular Medicine, University of Buffalo, Buffalo, NY
| | - Beni Rai Verma
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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28
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Xi Q, Liu Z, Song Y, Gan H, Huang Z, Luo Q, Zhao Z. Proteomic Analyses of Endarterectomized Tissues from Patients with Chronic Thromboembolic Pulmonary Hypertension. Cardiology 2019; 145:48-52. [PMID: 31734660 DOI: 10.1159/000502831] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND The pathogenesis of chronic thromboembolic pulmonary hypertension (CTEPH) is largely unknown. Proteomics offers an approach to overview the molecular activities and signal transduction pathways involved in specific disease processes. OBJECTIVES In this study, the expression of proteins in endarterectomized tissues from patients with CTEPH was investigated in a novel strategy to explore the pathophysiology of this disease. METHODS We used the iTRAQ (isobaric tag for relative and absolute quantitation) approach combined with a Thermo Scientific Q Exactive MS analysis to compare the protein profiles in endarterectomized tissues from CTEPH patients and that of the control samples (mixture of cultured human pulmonary artery endothelial cells, human pulmonary artery smooth muscle cells, and human pulmonary fibroblasts). GO and KEGG analyses were performed to understand the functional classification and molecular activities of all the tissue-specific proteins, and the involved signal transduction pathways. RESULTS Six hundred and seventy-nine tissue-specific proteins were detected. Bioinformatic analysis showed that the major biological processes involving these proteins were: response to wounding, defense response, acute inflammatory response, immune response, complement activation, and blood coagulation. The main pathways involved were: complement and coagulation cascade, systemic lupus erythematosus, extracellular matrix-receptor interaction, cell adhesion molecules, FcεRI signaling, and leukocyte transendothelial migration. CONCLUSIONS The present study revealed that immune and defense response might play an important role in CTEPH.
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Affiliation(s)
- Qunying Xi
- Department of Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences, Shenzhen, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
| | - Yunhu Song
- Center of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huili Gan
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China
| | - Zhiwei Huang
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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29
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Residual pulmonary hypertension is associated with clinical outcomes in patients with acute pulmonary thromboembolism. Heart Vessels 2019; 34:1866-1873. [DOI: 10.1007/s00380-019-01420-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
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30
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Undas A, Natorska J. Improving fibrinolysis in venous thromboembolism: impact of fibrin structure. Expert Rev Hematol 2019; 12:597-607. [PMID: 31159611 DOI: 10.1080/17474086.2019.1627193] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction. Fibrinolysis is of key importance in maintaining vessel patency. Impaired fibrinolysis associated with more compact fibrin structure has been shown in patients with venous thromboembolism (VTE), including deep-vein thrombosis and pulmonary embolism (PE). Currently, recombinant or modified plasminogen activators are the only commonly available thrombolytic agents. However, they are fraught with side effects and suboptimal effectiveness. Areas covered. Based on the available literature, the current evidence linking fibrinolysis with VTE and potential therapeutic targets among fibrinolysis proteins are presented. Expert opinion. Prolonged clot lysis time has been reported as a new predictor of first-time and recurrent VTE, including PE. Anticoagulant therapy, including non-vitamin K antagonist oral anticoagulants, has a favorable impact on fibrinolysis in VTE patients. Several VTE risk factors are also related to lower efficiency of fibrinolysis and their treatment improve fibrinolysis, in part by alterations to fibrin properties. There is an increasing number of studies aiming at developing novel profibrinolytic therapeutic agents for treatment of VTE patients, mostly targeting the antifibrinolytic proteins, i.e. antiplasmin, plasminogen activator inhibitor-1 and thrombin-activatable fibrinolysis inhibitor.
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Affiliation(s)
- Anetta Undas
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | - Joanna Natorska
- a Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
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31
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Zhang M, Zhang Y, Pang W, Zhai Z, Wang C. Circulating biomarkers in chronic thromboembolic pulmonary hypertension. Pulm Circ 2019; 9:2045894019844480. [PMID: 30942132 PMCID: PMC6552358 DOI: 10.1177/2045894019844480] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition characterized with chronic organized thrombi that obstruct the pulmonary vessels, leading to pulmonary hypertension (PH) and ultimately right heart failure. Although CTEPH is the only form of PH that can be cured with surgical intervention, not all patients with CTEPH will be deemed operable. Some CTEPH patients still have a poor prognosis. Therefore, the determination of diagnostic and prognostic biomarkers of CTEPH is of great importance for the early intervention to improve prognosis of patients with CTEPH. Several markers related to multiple mechanisms of CTEPH have been recently identified as circulating diagnostic and prognostic biomarkers in these patients. However, the existing literature review of biomarkers of CTEPH is relatively sparse. In this article, we review recent advances in circulating biomarkers of CTEPH and describe future applications of these biomarkers in the management of CTEPH.
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Affiliation(s)
- Meng Zhang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Yunxia Zhang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wenyi Pang
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- 2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Chen Wang
- 1 Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China.,2 Department of Respiratory and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China.,3 Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China.,4 National Clinical Research Center for Respiratory Diseases, Beijing, China.,5 Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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32
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disease with significant morbidity. It is a result of an alternate natural history in which there is limited resolution of thromboemboli with pulmonary artery obstruction leading to pulmonary hypertension (PH). CTEPH requires a thorough clinical assessment including pulmonary hemodynamics and radiologic evaluation in addition to consultation with an expert center. Surgical intervention remains the optimal management strategy. Select patients may be candidates for catheter-based intervention with balloon pulmonary angioplasty in centers with clinical expertise. Inoperable patients or those with post-intervention PH are treated with pulmonary hypertension-targeted medical therapy.
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Affiliation(s)
- Jean M Elwing
- Pulmonary Hypertension Program, Division of Pulmonary, Critical Care and Sleep Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML 0564, Cincinnati, OH 45267, USA.
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and Pulmonary Thromboendarterectomy Program, Advanced Heart Failure and Cardiac Transplant, Temple University School of Medicine, Temple University Hospital, 9th Floor Parkinson Pavilion, 3401 North Broad Street, Philadelphia, PA 19140, USA
| | - William R Auger
- CTEPH Program, UC San Diego Health, University of California, San Diego, 9300 Campus Point Drive #7381, La Jolla, CA 92037, USA
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33
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Soria J, Mirshahi S, Mirshahi SQ, Varin R, Pritchard LL, Soria C, Mirshahi M. Fibrinogen αC domain: Its importance in physiopathology. Res Pract Thromb Haemost 2019; 3:173-183. [PMID: 31011701 PMCID: PMC6462745 DOI: 10.1002/rth2.12183] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 11/22/2018] [Indexed: 12/17/2022] Open
Abstract
ABSTRACT Fibrinogen, involved in coagulation, is a soluble protein composed of two sets of disulfide-bridged Aα, Bβ, and γ-chains. In this review, we present the clinical implications of the αC domain of the molecule in Alzheimer's disease, hereditary renal amyloidosis and a number of thrombotic and hemorrhagic disorders. In Alzheimer's disease, amyloid beta peptide (Aβ) is increased and binds to the αC domain of normal fibrinogen, triggering increased fibrin(ogen) deposition in patients' brain parenchyma. In hereditary renal amyloidosis, fibrinogen is abnormal, with mutations located in the fibrinogen αC domain. The mutant αC domain derived from fibrinogen degradation folds incorrectly so that, in time, aggregates form, leading to amyloid deposits in the kidneys. In these patients, no thrombotic tendency has been observed. Abnormal fibrinogens with either a point mutation in the αC domain or a frameshift mutation resulting in absence of a part of the αC domain are often associated with either thrombotic events or bleeding. Mutation of an amino acid into cysteine (as in fibrinogens Dusart and Caracas V) or a frameshift mutation yielding an unpaired cysteine in the αC domain is often responsible for thrombotic events. Covalent binding of albumin to the unpaired cysteine via a disulphide bridge leads to decreased accessibility to the fibrinolytic enzymes, hence formation of poorly degradable fibrin clots, which explains the high incidence of thrombosis. In contrast, anomalies due to a frameshift mutation in the αC connector of the molecule, provoking deletion of a great part of the αC domain, are associated with bleeding.
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Affiliation(s)
- Jeannette Soria
- Laboratoire de recherche en Onco‐HématologieHôtel Dieu de ParisParisFrance
- INSERM U 965‐ CARTHôpital LariboisièreParisFrance
| | - Shahsoltan Mirshahi
- INSERM U 965‐ CARTHôpital LariboisièreParisFrance
- Diagnostica StagoGennevilliersFrance
| | | | - Remi Varin
- Faculté de Médecine et de PharmacieRouenFrance
| | - Linda L. Pritchard
- Laboratoire de recherche en Onco‐HématologieHôtel Dieu de ParisParisFrance
| | - Claudine Soria
- Laboratoire de recherche en Onco‐HématologieHôtel Dieu de ParisParisFrance
| | - Massoud Mirshahi
- Laboratoire de recherche en Onco‐HématologieHôtel Dieu de ParisParisFrance
- INSERM U 965‐ CARTHôpital LariboisièreParisFrance
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Salomon O, Barel O, Eyal E, Ganor RS, Kleinbaum Y, Shohat M. c.259A>C in the fibrinogen gene of alpha chain ( FGA) is a fibrinogen with thrombotic phenotype. APPLICATION OF CLINICAL GENETICS 2019; 12:27-33. [PMID: 30881084 PMCID: PMC6400116 DOI: 10.2147/tacg.s190599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction Dysfibrinogenemia is a rare inherited disease that results from mutation in one of the three fibrinogen genes. Diagnosis can be misleading since it may present as a bleeding tendency or thrombosis and a specific coagulation test for diagnosis is not routinely available Aim To search for a new candidate gene of thrombophilia in a family with three generations of arterial and venous thrombosis. Methods Whole exome sequencing followed by Sanger validation and segregation analysis was carried out. In addition, structural modeling was performed. Screening for thrombophilia along with blood counts, prothrombin time, activated partial thromboplastin, thrombin, reptilase time, and fibrinogen was done in each patient. Results and discussion A missense c.259A>C, p.K87Q (g.chr4: 155510050A-C) (rs764281241) in FGA gene was found in all three siblings without any other known thrombophilia marker to explain thrombosis in all three siblings. It is expected to be damaging by six out of seven prediction programs and is very rare in the entire population with Exac=0.000008. Conclusion The occurrence of the c.259A>C mutation in FGA may well explain the thrombosis phenotype of the affected family and is suggested as a new marker for thrombophilia phenotype.
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Affiliation(s)
- Ophira Salomon
- Institute of Thrombosis and Hemostasis, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ortal Barel
- Cancer Research Center, Wohl Institute of Translational Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Eyal
- Cancer Research Center, Wohl Institute of Translational Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Reut Shnerb Ganor
- The Bert W. Strassburger Lipid Center, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yeroham Kleinbaum
- Diagnostic Imaging, Department of Radiology, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mordechai Shohat
- Cancer Research Center, Wohl Institute of Translational Medicine, Sheba Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Molecular Research in Chronic Thromboembolic Pulmonary Hypertension. Int J Mol Sci 2019; 20:ijms20030784. [PMID: 30759794 PMCID: PMC6387321 DOI: 10.3390/ijms20030784] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 12/20/2022] Open
Abstract
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a debilitating disease, for which the underlying pathophysiological mechanisms have yet to be fully elucidated. Occurrence of a pulmonary embolism (PE) is a major risk factor for the development of CTEPH, with non-resolution of the thrombus being considered the main cause of CTEPH. Polymorphisms in the α-chain of fibrinogen have been linked to resistance to fibrinolysis in CTEPH patients, and could be responsible for development and disease progression. However, it is likely that additional genetic predisposition, as well as genetic and molecular alterations occurring as a consequence of tissue remodeling in the pulmonary arteries following a persistent PE, also play an important role in CTEPH. This review summarises the current knowledge regarding genetic differences between CTEPH patients and controls (with or without pulmonary hypertension). Mutations in BMPR2, differential gene and microRNA expression, and the transcription factor FoxO1 have been suggested to be involved in the processes underlying the development of CTEPH. While these studies provide the first indications regarding important dysregulated pathways in CTEPH (e.g., TGF-β and PI3K signaling), additional in-depth investigations are required to fully understand the complex processes leading to CTEPH.
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Chronic Thromboembolic Pulmonary Hypertension Cases Cluster in Families. Chest 2019; 155:384-390. [DOI: 10.1016/j.chest.2018.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/23/2018] [Accepted: 10/02/2018] [Indexed: 12/16/2022] Open
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Planquette B, Sanchez O, Marsh JJ, Chiles PG, Emmerich J, Le Gal G, Meyer G, Wolfson T, Gamst AC, Moore RE, Gugiu GB, Morris TA. Fibrinogen and the prediction of residual obstruction manifested after pulmonary embolism treatment. Eur Respir J 2018; 52:13993003.01467-2018. [PMID: 30337447 DOI: 10.1183/13993003.01467-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 09/24/2018] [Indexed: 11/05/2022]
Abstract
Residual pulmonary vascular obstruction (RPVO) and chronic thromboembolic pulmonary hypertension (CTEPH) are both long-term complications of acute pulmonary embolism, but it is unknown whether RPVO can be predicted by variants of fibrinogen associated with CTEPH.We used the Akaike information criterion to select the best predictive models for RPVO in two prospectively followed cohorts of acute pulmonary embolism patients, using as candidate variables the extent of the initial obstruction, clinical characteristics and fibrinogen-related data. We measured the selected models' goodness of fit by analysis of deviance and compared models using the Chi-squared test.RPVO occurred in 29 (28.4%) out of 102 subjects in the first cohort and 46 (25.3%) out of 182 subjects in the second. The best-fit predictive model derived in the first cohort (p=0.0002) and validated in the second cohort (p=0.0005) implicated fibrinogen Bβ-chain monosialylation in the development of RPVO. When the derivation procedure excluded clinical characteristics, fibrinogen Bβ-chain monosialylation remained a predictor of RPVO in the best-fit predictive model (p=0.00003). Excluding fibrinogen characteristics worsened the predictive model (p=0.03).Fibrinogen Bβ-chain monosialylation, a common structural attribute of fibrin, helped predict RPVO after acute pulmonary embolism. Fibrin structure may contribute to the risk of developing RPVO.
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Affiliation(s)
- Benjamin Planquette
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM UMR-S 1140, Paris, France
| | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM UMR-S 1140, Paris, France
| | - James J Marsh
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Peter G Chiles
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Joseph Emmerich
- Université Paris Descartes, Sorbonne Paris Cité, France.,Médecine Vasculaire - Cardiologie, Centre de Diagnostic et de Thérapeutique, Hôpital Hôtel Dieu, AP-HP, Paris, France
| | - Grégoire Le Gal
- Dept of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Guy Meyer
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM CIC-1418, Paris, France.,INSERM UMR-S 970, Paris, France
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California San Diego, San Diego, CA, USA
| | - Anthony C Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California San Diego, San Diego, CA, USA
| | - Roger E Moore
- Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Gabriel B Gugiu
- Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Timothy A Morris
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
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Wilkens H, Konstantinides S, Lang IM, Bunck AC, Gerges M, Gerhardt F, Grgic A, Grohé C, Guth S, Held M, Hinrichs JB, Hoeper MM, Klepetko W, Kramm T, Krüger U, Lankeit M, Meyer BC, Olsson KM, Schäfers HJ, Schmidt M, Seyfarth HJ, Ulrich S, Wiedenroth CB, Mayer E. Chronic thromboembolic pulmonary hypertension (CTEPH): Updated Recommendations from the Cologne Consensus Conference 2018. Int J Cardiol 2018; 272S:69-78. [PMID: 30195840 DOI: 10.1016/j.ijcard.2018.08.079] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 08/24/2018] [Indexed: 10/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a subgroup of pulmonary hypertension that differs from all other forms of PH in terms of its pathophysiology, patient characteristics and treatment. For implementation of the European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension in Germany, the Cologne Consensus Conference 2016 was held and last updated in spring of 2018. One of the working groups was dedicated to CTEPH, practical and controversial issues were commented and updated. In every patient with suspected PH, CTEPH or chronic thromboembolic disease (CTED, i.e. symptomatic residual vasculopathy without pulmonary hypertension) should be excluded. Primary treatment is surgical pulmonary endarterectomy (PEA) in a multidisciplinary CTEPH centre. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. There is increasing experience with balloon pulmonary angioplasty (BPA) for inoperable patients; this option, like PEA, is reserved for specialised centres with expertise in this treatment method.
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Affiliation(s)
- Heinrike Wilkens
- Department of Internal Medicine V - Pneumology, Allergology and Critical Care Medicine, University Hospital of Saarland, 66421 Homburg, Saar, Germany.
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes-Gutenberg Universität Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Irene M Lang
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Alexander C Bunck
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | - Mario Gerges
- Klinik für Innere Medizin II, Abt. Kardiologie, Medizinische Universität Wien, Austria
| | - Felix Gerhardt
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinik Köln, Germany
| | | | - Christian Grohé
- Klinik für Pneumologie Evangelische Lungenklinik Berlin, Buch, 13125 Berlin, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Matthias Held
- Missionsärztliche Klinik Würzburg, Innere Medizin, Pneumologie/Kardiologie, Zentrum für pulmonale Hyertonie und Lungengefäßkrankheiten, Germany
| | - Jan B Hinrichs
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Deutsches Zentrum für Lungenforschung (DZL), Germany
| | - Walter Klepetko
- Klinische Abteilung für Thoraxchirurgie, Medizinische Universität Wien, Austria
| | - Thorsten Kramm
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ulrich Krüger
- Klinik für Kardiologie und Angiologie, Herzzentrum Duisburg, Germany
| | - Mareike Lankeit
- Medizinische Klinik mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Bernhard C Meyer
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Germany
| | - Karen M Olsson
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, 66421 Homburg, Germany
| | - Matthias Schmidt
- Klinik und Poliklinik für Nuklearmedizin, Universitätsklinikum Köln, 50937 Köln, Germany
| | - Hans-J Seyfarth
- Abteilung Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig, Germany
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff-Clinic GmbH, Benekestr. 2-8, 61231 Bad Nauheim, Germany
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Abstract
Pulmonary embolism (PE) is caused by emboli, which have originated from venous thrombi, travelling to and occluding the arteries of the lung. PE is the most dangerous form of venous thromboembolism, and undiagnosed or untreated PE can be fatal. Acute PE is associated with right ventricular dysfunction, which can lead to arrhythmia, haemodynamic collapse and shock. Furthermore, individuals who survive PE can develop post-PE syndrome, which is characterized by chronic thrombotic remains in the pulmonary arteries, persistent right ventricular dysfunction, decreased quality of life and/or chronic functional limitations. Several important improvements have been made in the diagnostic and therapeutic management of acute PE in recent years, such as the introduction of a simplified diagnostic algorithm for suspected PE as well as phase III trials demonstrating the value of direct oral anticoagulants in acute and extended treatment of venous thromboembolism. Future research should aim to address novel treatment options (for example, fibrinolysis enhancers) and improved methods for predicting long-term complications and defining optimal anticoagulant therapy parameters in individual patients, and to gain a greater understanding of post-PE syndrome.
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41
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Epidemiology and risk factors for chronic thromboembolic pulmonary hypertension. Thromb Res 2018; 164:145-149. [DOI: 10.1016/j.thromres.2018.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 01/05/2018] [Accepted: 01/07/2018] [Indexed: 11/20/2022]
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43
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an uncommon and late complication of pulmonary embolism resulting from misguided remodelling of residual pulmonary thromboembolic material and small-vessel arteriopathy. CTEPH is the only form of pulmonary hypertension (PH) potentially curable by pulmonary endarterectomy (PEA). Unfortunately, several patients have either an unacceptable risk-benefit ratio for undergoing the surgical intervention or develop persistent PH after PEA. Novel medical and endovascular therapies can be considered for them. The soluble guanylate cyclase stimulator riociguat is recommended for the treatment of patients with inoperable disease or with recurrent/persistent PH after PEA. Other drugs developed for the treatment of other forms of PH, as prostanoids, phosphodiesterase-5 inhibitors and endothelin receptor antagonists have been used in the treatment of CTEPH, with limited benefit. Balloon pulmonary angioplasty is a novel and promising technique and is progressively emerging from the pioneering phase. Highly specialized training level and complex protocols of postoperative care are mandatory to consolidate the technical success of the surgical and endovascular intervention.
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Affiliation(s)
| | - Paolo Prandoni
- Department of Cardiac Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Abstract
After achievement of adequate anticoagulation, the natural history of acute pulmonary emboli ranges from near total resolution of vascular perfusion to long-term persistence of hemodynamically consequential residual perfusion defects. The persistence of perfusion defects is necessary, but not sufficient, for the development of chronic thromboembolic pulmonary hypertension (CTEPH). Approximately 30% of patients have persistent defects after 6 months of anticoagulation, but only 10% of those with persistent defects subsequently develop CTEPH. A number of clinical risk factors including increasing age, delay in anticoagulation from symptom onset, and the size of the initial thrombus have been associated with the persistence of perfusion defects. Likewise, a number of cellular and molecular pathways have been implicated in the failure of thrombus resolution, including impaired fibrinolysis, altered fibrinogen structure and function, increased local or systemic inflammation, and remodeling of the embolic material by neovascularization. Treatment with fibrinolytic agents at the time of initial presentation has not clearly improved the frequency or degree of recovery of pulmonary vascular perfusion. A better understanding of the interplay between clinical risk factors and pathogenic mechanisms may enhance the ability to prevent and treat CTEPH in the future.
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Undas A. Fibrin clot properties and their modulation in thrombotic disorders. Thromb Haemost 2017; 112:32-42. [DOI: 10.1160/th14-01-0032] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Accepted: 02/19/2014] [Indexed: 11/05/2022]
Abstract
SummaryAccumulating evidence indicates that accelerated formation of fibrin clots composed of compact, highly-branched networks with thin fibres which are relatively resistant to plasmin-mediated lysis can be commonly observed in patients with venous or arterial thrombosis. This review discusses characteristics of fibrin clot structure and function in patients with various thromboembolic manifestations, in particular myocardial infarction, ischaemic stroke and venous thromboembolism, based on the publications till December 2013. Moreover, factors will be presented that in vivo unfavourably determine altered fibrin clot properties in thrombotic disorders and modalities that can improve clot phenotype.
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Chitlur M, Brennan SO. Hypodysfibrinogenaemia and thrombosis in association with a new fibrinogen γ chain with two mutations (γ114Tyr→His, and γ320Asp deleted). Thromb Haemost 2017; 109:1180-2. [DOI: 10.1160/th13-01-0068] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2013] [Accepted: 02/20/2013] [Indexed: 11/05/2022]
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Riedelová-Reicheltová Z, Kotlín R, Suttnar J, Geierová V, Riedel T, Májek P, Dyr JE. A novel natural mutation AαPhe98Ile in the fibrinogen coiled-coil affects fibrinogen function. Thromb Haemost 2017; 111:79-87. [DOI: 10.1160/th13-04-0267] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 09/05/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe aim of this study was to investigate the structure and function of fibrinogen obtained from a patient with normal coagulation times and idiopathic thrombophilia. This was done by SDS-PAGE and DNA sequence analyses, scanning electron microscopy, fibrinopeptide release, fibrin polymerisation initiated by thrombin and reptilase, fibrinolysis, and platelet aggregometry. A novel heterozygous point mutation in the fibrinogen Aα chain, Phe98 to Ile, was found and designated as fibrinogen Vizovice. The mutation, which is located in the RGDF sequence (Aα 95–98) of the fibrinogen coiled-coil region, significantly affected fibrin clot morphology. Namely, the clot formed by fibrinogen Vizovice contained thinner and curled fibrin fibers with reduced length. Lysis of the clots prepared from Vizovice plasma and isolated fibrinogen were found to be impaired. The lysis rate of Vizovice clots was almost four times slower than the lysis rate of control clots. In the presence of platelets agonists the mutant fibrinogen caused increased platelet aggregation. The data obtained show that natural mutation of Phe98 to Ile in the fibrinogen Aα chain influences lateral aggregation of fibrin protofibrils, fibrinolysis, and platelet aggregation. They also suggest that delayed fibrinolysis, together with the abnormal fibrin network morphology and increased platelet aggregation, may be the direct cause of thrombotic complications in the patient associated with pregnancy loss.
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Zia A, Russell J, Sarode R, Veeram SR, Josephs S, Malone K, Zhang S, Journeycake J. Markers of coagulation activation, inflammation and fibrinolysis as predictors of poor outcomes after pediatric venous thromboembolism: A systematic review and meta-analysis. Thromb Res 2017; 160:1-8. [PMID: 29078111 DOI: 10.1016/j.thromres.2017.10.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/28/2017] [Accepted: 10/03/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Sequelae of venous thromboembolism (VTE) in children include recurrence, development of post thrombotic syndrome (PTS) when venous return from a limb is affected and chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism. Identification of laboratory-based risk factors may be useful for individualized risk assessment for VTE sequelae. Coagulation activation and inflammation may contribute to their pathophysiology. We performed a systematic review to investigate the association between biomarkers of coagulation activation, inflammation and fibrinolysis and adverse VTE outcomes in children and young adults. METHODS A systematic search of electronic databases, PubMed (NIH), EMBASE (Ovid), Web of Science (Thompson Reuters), and SCOPUS (Elsevier) for studies published through November 2016 was conducted using "VTE" including MeSH terms for "coagulation activation," "inflammation" and "fibrinolysis," with no limit on publication date. A study was eligible for inclusion when it evaluated patients (< 21years) with VTE and biomarkers of coagulation activation, inflammation, and fibrinolysis and assessed for their association with development of adverse thrombotic outcomes. A modified Newcastle Ottawa Scale was applied to examine the quality of included studies. RESULTS Our search strategy yielded 200 references. A total of 3 cohort studies representing 220 patients with VTE were included. Two authors independently assessed all references for inclusion. Three studies (2 prospective cohort and one mixed cohort study) were identified that reported on biomarkers of coagulation activation, inflammation and fibrinolysis, checked at least once after VTE diagnosis and assessed association with primary outcomes of recurrent VTE, PTS and CTEPH. Studies varied with regards to definition of outcomes, the type of biomarkers measured and time point of measurement. We were unable to meta-analyze results due to marked clinical heterogeneity and <3 studies available for each biomarker. Descriptively, a significant association was found for elevated plasma levels of FVIII and D-dimer for a compound outcome of PTS, recurrence and progression in one study, and positive lupus anticoagulant at DVT diagnosis and subsequent PTS by another study. No studies were found for CTEPH. CONCLUSIONS Elevated D-dimer, FVIII and lupus anticoagulant show promise for predicting recurrent VTE and PTS in children and young adults. Further research is needed to elucidate whether these markers might be useful to predict development of adverse outcomes after VTE in children.
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Affiliation(s)
- Ayesha Zia
- Division of Pediatric Hematology/Oncology; Children's Medical Center, United States; The University of Texas Southwestern Medical Center, United States.
| | - Joy Russell
- Health Sciences Digital Library and Learning Center; The University of Texas Southwestern Medical Center, United States
| | - Ravi Sarode
- Department of Pathology; The University of Texas Southwestern Medical Center, United States
| | - Surendranath R Veeram
- Children's Medical Center, United States; Division of Pediatric Interventional Cardiology; The University of Texas Southwestern Medical Center, United States
| | - Shellie Josephs
- Children's Medical Center, United States; Division of Pediatric Interventional Radiology; The University of Texas Southwestern Medical Center, United States
| | | | - Song Zhang
- The Department of Clinical Sciences; The University of Texas Southwestern Medical Center, United States
| | - Janna Journeycake
- Division of Pediatric Hematology/Oncology; Children's Medical Center, United States; The University of Texas Southwestern Medical Center, United States
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Siddique S, Risse J, Canaud G, Zuily S. Vascular Manifestations in Antiphospholipid Syndrome (APS): Is APS a Thrombophilia or a Vasculopathy? Curr Rheumatol Rep 2017; 19:64. [PMID: 28871481 DOI: 10.1007/s11926-017-0687-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Antiphospholipid antibody syndrome (APS) is characterized primarily by thrombosis and pregnancy morbidity. Chronic vascular lesions can also occur. While the underlying mechanisms of these vascular lesions are not entirely known, there have been multiple theories describing the potential process of vasculopathy in APS and the various clinical manifestations associated with it. RECENT FINDINGS Recently, it has been demonstrated that endothelial proliferation in kidneys can be explained by the activation of the mammalian target of rapamycin complex (mTORC) pathway by antiphospholipid antibodies (aPL). These data support the existence of an APS-related vasculopathy in different locations which can explain-in part-the different manifestations of APS. This review focuses on the various manifestations of APS as a result of APS-related vasculopathy, as well as pathophysiology, current screening, and treatment options for clinicians to be aware of.
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Affiliation(s)
- Salma Siddique
- Division of Rheumatology, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY, 10021, USA.
| | - Jessie Risse
- CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases, Inserm U1116 at Lorraine University, Nancy, France
| | - Guillaume Canaud
- Université Paris Descartes, Sorbonne Paris Cité; Inserm U1151, Institut Necker-Enfants Malades; Service de Néphrologie Transplantation Adultes, Hôpital Necker-Enfants Malades, Paris, France
| | - Stéphane Zuily
- CHRU de Nancy, Vascular Medicine Division and Regional Competence Center For Rare Vascular And Systemic Autoimmune Diseases, Inserm U1116 at Lorraine University, Nancy, France
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Undas A. Prothrombotic Fibrin Clot Phenotype in Patients with Deep Vein Thrombosis and Pulmonary Embolism: A New Risk Factor for Recurrence. BIOMED RESEARCH INTERNATIONAL 2017; 2017:8196256. [PMID: 28740853 PMCID: PMC5504927 DOI: 10.1155/2017/8196256] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/27/2017] [Accepted: 05/04/2017] [Indexed: 11/23/2022]
Abstract
Prothrombotic fibrin clot phenotype, involving faster formation of dense meshwork composed of thinner and highly branched fibers that are relatively resistant to plasmin-induced lysis, has been reported in patients with not only myocardial infarction or stroke, but also venous thromboembolism (VTE), encompassing deep vein thrombosis (DVT), and/or pulmonary embolism (PE). Prothrombotic fibrin clot phenotype, in particular prolonged clot lysis time, is considered a novel risk factor for VTE as well as venous thrombosis at unusual location, for example, cerebral sinus venous thrombosis, retinal vein obstruction, and Budd-Chiari syndrome. Growing evidence from observational studies indicates that abnormal fibrin clot properties can predict recurrent DVT and PE and they are involved in serious complications of VTE, for example, thromboembolic pulmonary hypertension and postthrombotic syndrome. The purpose of this article is to review our current understanding of the role of fibrin clot structure and function in venous thrombosis with emphasis on clinical issues ranging from prognosis to therapy.
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Affiliation(s)
- Anetta Undas
- Institute of Cardiology, Jagiellonian University School of Medicine and The John Paul II Hospital, Krakow, Poland
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