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Mangeshkar S, Borkowski P, Singh N, Zoumpourlis P, Maliha M, Nagraj S, Kharawala A, Faillace R. Sex differences in Chronic Thromboembolic Pulmonary Hypertension. Future Cardiol 2024:1-10. [PMID: 39157860 DOI: 10.1080/14796678.2024.2385872] [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: 05/18/2024] [Accepted: 07/25/2024] [Indexed: 08/20/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed sequela of acute pulmonary embolism with varied clinical presentation causing significant morbidity among the affected population. There exist important differences in the occurrence, clinical features and diagnosis of CTEPH between men and women, with women carrying a greater predisposition for the disease. Ongoing studies have also pointed out variations among men and women, in the treatment offered and long-term outcomes including mortality. This focused review article highlights important sex-associated differences in multiple aspects of CTEPH including its epidemiology, clinical features, diagnosis, treatment and outcomes as reported in current literature and highlights the need for future research to facilitate a clearer understanding of these differences.
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Affiliation(s)
- Shaunak Mangeshkar
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Pawel Borkowski
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Nikita Singh
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Panagiotis Zoumpourlis
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Maisha Maliha
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Sanjana Nagraj
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 E 210th St, Bronx, NY 10467, USA
| | - Amrin Kharawala
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
| | - Robert Faillace
- Department of Internal Medicine, Jacobi Medical Center/Albert Einstein College of Medicine, 1400 Pelham Parkway S, Bronx, NY 10461, USA
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Barnes H, Niewodowski D, Doi A, Marasco S, Joseph T, Siemienowicz M, Keating D, Yo S, Kaye D, Williams T, McGiffin D, Whitford H. Current surgical management of chronic thromboembolic pulmonary disease. Intern Med J 2024. [PMID: 39087843 DOI: 10.1111/imj.16470] [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: 04/12/2024] [Accepted: 06/04/2024] [Indexed: 08/02/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) with or without pulmonary hypertension (PH) is an important potential consequence of venous thromboembolic disease. Untreated CTEPD with pulmonary hypertension (CTEPH) is associated with high rates of morbidity and mortality. Several treatment options are now available for patients with CTEPD and CTEPH, including pulmonary endarterectomy (PEA), balloon pulmonary angioplasty, medical therapy or a combination of therapies. Choice of treatment depends on the location of the thromboembolic disease burden, presence and severity of PH and patient factors, including frailty, parenchymal lung disease and other comorbidities. PEA is a complex surgery that can result in excellent outcomes and resolution of disease, but also comes with the risk of serious perioperative complications. This manuscript examines the history of PEA and its place in Australasia, and reports on outcomes from the main Australasian CTEPH expert centre. It provides a summary of up-to-date guidance on how PEA should be utilised in the overall management of these patients and describes opportunities and challenges for the future diagnosis and management of this disease, particularly in the Australasian setting.
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Affiliation(s)
- Hayley Barnes
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Daniel Niewodowski
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
| | - Atsuo Doi
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Silvana Marasco
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Tim Joseph
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Miranda Siemienowicz
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Dominic Keating
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shaun Yo
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - David Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Trevor Williams
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
| | - David McGiffin
- Department of Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Helen Whitford
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- School of Translational Medicine, Monash University, Melbourne, Victoria, Australia
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Zhang Z, Liu J, Zhen Y, Liu X, Xu M, Ma J, Wen J, Liu P. Riociguat as bridging therapy to pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension: a retrospective cohort study. J Thorac Dis 2024; 16:3540-3552. [PMID: 38983143 PMCID: PMC11228705 DOI: 10.21037/jtd-24-48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/26/2024] [Indexed: 07/11/2024]
Abstract
Background In operable chronic thromboembolic pulmonary hypertension (CTEPH) patients, the utilization of bridging therapy with targeted medications prior to pulmonary endarterectomy (PEA) remains a topic of controversy, despite being common in cases of severe hemodynamic impairment. This study aims to assess the impact of riociguat as a bridging therapy on postoperative hemodynamics and outcomes. Methods We conducted a retrospective study involving patients undergoing PEA from December 2016 to November 2023. Patients were categorized into two groups based on the use of riociguat before PEA. Pulmonary vascular resistance (PVR) following riociguat administration was assessed pre-PEA. Postoperative outcomes, including mortality, complications, and hemodynamics, were compared, employing propensity score matching analysis. Results Among the patients, 41.8% (n=56) received riociguat as bridging therapy. In patients with PVR ≥800 dynes·sec·cm-5, riociguat resulted in a reduction in PVR {1,207 [974-1,698] vs. 1,125 [928-1,486] dynes·sec·cm-5, P<0.01}, while no significant difference was observed in patients with PVR <800 dynes·sec·cm-5 {641 [474-740] vs. 600 [480-768] dynes·sec·cm-5, P=0.46}. After propensity score matching, each group included 26 patients. The overall perioperative mortality rate was 2.6%. Postoperative PVR {326 [254-398] vs. 361 [290-445] dynes·sec·cm-5, P=0.35} was similar in the riociguat group compared to the control group. The incidence of residual pulmonary hypertension (PH) and other postoperative outcomes were also comparable. Conclusions The use of riociguat as bridging therapy demonstrated hemodynamic improvement before PEA in patients with high preoperative PVR. However, no additional benefits in postoperative mortality or hemodynamics were observed.
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Affiliation(s)
- Zhaohua Zhang
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jingwen Liu
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Mingyuan Xu
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Junyu Ma
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, Beijing, China
| | - Jianyan Wen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Peng Liu
- Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
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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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Gonzalez-Hermosillo LM, Cueto-Robledo G, Navarro-Vergara DI, Garcia-Cesar M, Torres-Rojas MB, Graniel-Palafox LE, Castro-Escalante KY, Castro-Diaz AM. Post-pulmonary embolism syndrome: A reminder for clinicians. Asian Cardiovasc Thorac Ann 2024; 32:336-344. [PMID: 39135401 DOI: 10.1177/02184923241272913] [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: 09/03/2024]
Abstract
Acute pulmonary embolism (APE) is one of the leading causes of cardiovascular emergencies and the third leading cause of death. Although efforts focus on treating the acute event, patients who survive APE may develop long-term sequelae. Research reveals that approximately half of patients who have suffered an APE do not regain their previous level of function and experience a reduction in their quality of life for several years after the episode. Acute pulmonary embolism can be classified according to the risk of short-term mortality, with most mortality and morbidity concentrated in high-risk and intermediate-risk cases. The first-line treatment for APE is systemic anticoagulation. However, identifying and more aggressively treating people with intermediate to high risk, who have a more favorable risk profile for reperfusion treatments, could reduce short-term mortality and mitigate post-pulmonary embolism syndrome (PPES). Post-pulmonary embolism syndrome refers to a variety of persistent symptoms and functional limitations that occur after an APE. The presence of persistent dyspnea, functional limitations, and/or decreased quality of life after an APE has been recently termed "PPES," although this entity encompasses different manifestations. The most severe cause of persistent dyspnea is chronic thromboembolic pulmonary hypertension, where increased pulmonary artery pressure is due to the fibrotic organization of unresolved APE. Post-PE Syndrome is not always systematically addressed in management guidelines, and its prevalence may be underestimated. More research is needed to fully understand its causes and risk factors. Interventions such as cardiopulmonary rehabilitation have been suggested to improve the quality of life of patients with PPES. A comprehensive, evidence-based approach is essential to effectively prevent and manage PPES and improve the long-term outcomes and well-being of affected patients.
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Affiliation(s)
| | - Guillermo Cueto-Robledo
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
- Pulmonary Circulation Clinic, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
- Faculty of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
| | - Dulce-Iliana Navarro-Vergara
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Marisol Garcia-Cesar
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Maria-Berenice Torres-Rojas
- Doctorate Program in Biomedical Sciences, Postgraduate Unit, National Autonomous University of Mexico, Mexico City, Mexico
- Cardiorespiratory Emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
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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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7
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Abdulaal L, Maiter A, Salehi M, Sharkey M, Alnasser T, Garg P, Rajaram S, Hill C, Johns C, Rothman AMK, Dwivedi K, Kiely DG, Alabed S, Swift AJ. A systematic review of artificial intelligence tools for chronic pulmonary embolism on CT pulmonary angiography. FRONTIERS IN RADIOLOGY 2024; 4:1335349. [PMID: 38654762 PMCID: PMC11035730 DOI: 10.3389/fradi.2024.1335349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/26/2024] [Indexed: 04/26/2024]
Abstract
Background Chronic pulmonary embolism (PE) may result in pulmonary hypertension (CTEPH). Automated CT pulmonary angiography (CTPA) interpretation using artificial intelligence (AI) tools has the potential for improving diagnostic accuracy, reducing delays to diagnosis and yielding novel information of clinical value in CTEPH. This systematic review aimed to identify and appraise existing studies presenting AI tools for CTPA in the context of chronic PE and CTEPH. Methods MEDLINE and EMBASE databases were searched on 11 September 2023. Journal publications presenting AI tools for CTPA in patients with chronic PE or CTEPH were eligible for inclusion. Information about model design, training and testing was extracted. Study quality was assessed using compliance with the Checklist for Artificial Intelligence in Medical Imaging (CLAIM). Results Five studies were eligible for inclusion, all of which presented deep learning AI models to evaluate PE. First study evaluated the lung parenchymal changes in chronic PE and two studies used an AI model to classify PE, with none directly assessing the pulmonary arteries. In addition, a separate study developed a CNN tool to distinguish chronic PE using 2D maximum intensity projection reconstructions. While another study assessed a novel automated approach to quantify hypoperfusion to help in the severity assessment of CTEPH. While descriptions of model design and training were reliable, descriptions of the datasets used in training and testing were more inconsistent. Conclusion In contrast to AI tools for evaluation of acute PE, there has been limited investigation of AI-based approaches to characterising chronic PE and CTEPH on CTPA. Existing studies are limited by inconsistent reporting of the data used to train and test their models. This systematic review highlights an area of potential expansion for the field of AI in medical image interpretation.There is limited knowledge of A systematic review of artificial intelligence tools for chronic pulmonary embolism in CT. This systematic review provides an assessment on research that examined deep learning algorithms in detecting CTEPH on CTPA images, the number of studies assessing the utility of deep learning on CTPA in CTEPH was unclear and should be highlighted.
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Affiliation(s)
- Lojain Abdulaal
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Faculty of Applied Medical Science, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Maiter
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Respiratory Physiology Department, Sheffield Pulmonary Vascular Disease Unit, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Mahan Salehi
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Michael Sharkey
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Turki Alnasser
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Pankaj Garg
- Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Smitha Rajaram
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Respiratory Physiology Department, Sheffield Pulmonary Vascular Disease Unit, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Catherine Hill
- Respiratory Physiology Department, Sheffield Pulmonary Vascular Disease Unit, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Christopher Johns
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Respiratory Physiology Department, Sheffield Pulmonary Vascular Disease Unit, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Alex Matthew Knox Rothman
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
| | - Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Respiratory Physiology Department, Sheffield Pulmonary Vascular Disease Unit, Sheffield, United Kingdom
| | - David G. Kiely
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Faculty of Engineering, INSIGNEO Institute, Institute for in Silico Medicine, The University of Sheffield, Sheffield, United Kingdom
- Sheffield Biomedical Research Centre, National Institute for Health Research, Sheffield, United Kingdom
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Faculty of Engineering, INSIGNEO Institute, Institute for in Silico Medicine, The University of Sheffield, Sheffield, United Kingdom
| | - Andrew James Swift
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, United Kingdom
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
- Faculty of Engineering, INSIGNEO Institute, Institute for in Silico Medicine, The University of Sheffield, Sheffield, United Kingdom
- Sheffield Biomedical Research Centre, National Institute for Health Research, Sheffield, United Kingdom
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8
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Veen KM, Koudstaal T, Hendriks PM, Takkenberg JJ, Boomars KA, van den Bosch AE. Prognostic value of tricuspid valve regurgitation in patients with pulmonary arterial hypertension and CTEPH: A longitudinal study. INTERNATIONAL JOURNAL OF CARDIOLOGY. HEART & VASCULATURE 2024; 51:101342. [PMID: 38389829 PMCID: PMC10882103 DOI: 10.1016/j.ijcha.2024.101342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/08/2024] [Accepted: 01/11/2024] [Indexed: 02/24/2024]
Abstract
Aims The prognostic value of functional tricuspid valve regurgitation (TR) in patients with pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension (CTEPH) remains undetermined. This study primarily aims to quantify the prognostic role of TR in relation to right ventricle (RV) dysfunction on clinical outcomes and secondarily the evolution of TR and RV dysfunction over time. Methods Adult PAH or CTEPH patients diagnosed by right heart catheterization were included. Exclusion criteria were prevalent patients and age < 18 years.The primary endpoint was a composite of death or lung transplantation. Longitudinal evolution of TR and RV dysfunction were modelled with generalized mixed-effect models, which were inserted in a cox model under the joint-modelling framework in order to investigate the association of TR and RV dysfunction with the endpoint. Results We included 76 PAH and 44 CTEPH patients (median age:59, females:62 %), with a mean follow-up of 3.2 ± 2.1 years. 31 patients reached the endpoint (2 transplant, 29 mortality). On average the probability of moderate-to-severe TR decreased during follow-up, whereas the probability of moderate-to-severe RV dysfunction remained stable. The cumulative effect of moderate-to-severe TR (HRper day 1.01 95 %CI[1.00-1.01],P < 0.001) and moderate-to-severe RV dysfunction (HRper day: 1.01 95 %CI[1.00-1.01],P < 0.001) was associated with the endpoint in univariable joint-models. In a multivariable joint-model with both the evolutions of TR and RV dysfunction only TR remained significant (HR per day: 1.01 95 %CI[1.00-1.01],P < 0.001). Conclusion Persistent moderate-to-severe tricuspid valve regurgitation during follow-up predicts adverse outcomes and might be a better predictor of lung transplantation and mortality compared to right ventricle dysfunction.
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Affiliation(s)
- Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Thomas Koudstaal
- Department of Pulmonary medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Paul M Hendriks
- Department of Pulmonary medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Johanna Jm Takkenberg
- Department of Cardiothoracic Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Karin A Boomars
- Department of Pulmonary medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Annemien E van den Bosch
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, the Netherlands
- ERN-GUARD-Heart: European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart, the Netherlands
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9
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Meyer FJ, Opitz C. Post-Pulmonary Embolism Syndrome: An Update Based on the Revised AWMF-S2k Guideline. Hamostaseologie 2024; 44:128-134. [PMID: 38531395 DOI: 10.1055/a-2229-4190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
In survivors of acute pulmonary embolism (PE), the post-PE syndrome (PPES) may occur. In PPES, patients typically present with persisting or progressive dyspnea on exertion despite 3 months of therapeutic anticoagulation. Therefore, a structured follow-up is warranted to identify patients with chronic thromboembolic pulmonary disease (CTEPD) with normal pulmonary pressure or chronic thromboembolic pulmonary hypertension (CTEPH). Both are currently understood as a dual vasculopathy, that is, secondary arterio- and arteriolopathy, affecting the large and medium-sized pulmonary arteries as well as the peripheral vessels (diameter < 50 µm). The follow-up algorithm after acute PE commences with identification of clinical symptoms and risk factors for CTEPH. If indicated, a stepwise performance of echocardiography, ventilation-perfusion scan (or alternative imaging), N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level, cardiopulmonary exercise testing, and pulmonary artery catheterization with angiography should follow. CTEPH patients should be treated in a multidisciplinary center with adequate experience in the complex therapeutic options, comprising pulmonary endarterectomy, balloon pulmonary angioplasty, and pharmacological interventions.
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Affiliation(s)
- F Joachim Meyer
- Lungenzentrum München (Bogenhausen-Harlaching) - München Klinik gGmbH, Sanatoriumsplatz 2 München, München, Bavaria, Germany
| | - Christian Opitz
- Klinik für Innere Medizin, Schwerpunkt Kardiologie, DRK Kliniken Berlin Westend, Berlin, Germany
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Bongiovanni G, Tonutti A, Stainer A, Nigro M, Kellogg DL, Nambiar A, Gramegna A, Mantero M, Voza A, Blasi F, Aliberti S, Amati F. Vasoactive drugs for the treatment of pulmonary hypertension associated with interstitial lung diseases: a systematic review. BMJ Open Respir Res 2024; 11:e002161. [PMID: 38479818 PMCID: PMC10941167 DOI: 10.1136/bmjresp-2023-002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES Vasoactive drugs have exhibited clinical efficacy in addressing pulmonary arterial hypertension, manifesting a significant reduction in morbidity and mortality. Pulmonary hypertension may complicate advanced interstitial lung disease (PH-ILD) and is associated with high rates of disability, hospitalisation due to cardiac and respiratory illnesses, and mortality. Prior management hinged on treating the underlying lung disease and comorbidities. However, the INCREASE trial of inhaled treprostinil in PH-ILD has demonstrated that PH-ILD can be effectively treated with vasoactive drugs. METHODS This comprehensive systematic review examines the evidence for vasoactive drugs in the management of PH-ILD. RESULTS A total of 1442 pubblications were screened, 11 RCTs were considered for quantitative synthesis. Unfortunately, the salient studies are limited by population heterogeneity, short-term follow-up and the selection of outcomes with uncertain clinical significance. CONCLUSIONS This systematic review underscores the necessity of establishing a precision medicine-oriented strategy, directed at uncovering and addressing the intricate cellular and molecular mechanisms that underlie the pathophysiology of PH-ILD. PROSPERO REGISTRATION NUMBER CRD42023457482.
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Affiliation(s)
- Gabriele Bongiovanni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Anna Stainer
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Mattia Nigro
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
| | - Dean L Kellogg
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Health San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Anoop Nambiar
- Division of Pulmonary and Critical Care, Department of Medicine, University of Texas Health San Antonio and the South Texas Veterans Health Care System, San Antonio, Texas, USA
| | - Andrea Gramegna
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Mantero
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Voza
- Emergency Medicine Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Blasi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
- Respiratory Unit and Cystic Fibrosis Adult Center, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Aliberti
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Francesco Amati
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072, Pieve Emanuele, Milan, Italy
- Respiratory Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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11
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Zhan S, Wang L, Wang W, Li R. Analysis of genes characterizing chronic thrombosis and associated pathways in chronic thromboembolic pulmonary hypertension. PLoS One 2024; 19:e0299912. [PMID: 38451963 PMCID: PMC10919650 DOI: 10.1371/journal.pone.0299912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/17/2024] [Indexed: 03/09/2024] Open
Abstract
PURPOSE In chronic thromboembolic pulmonary hypertension (CTEPH), fibrosis of thrombi in the lumen of blood vessels and obstruction of blood vessels are important factors in the progression of the disease. Therefore, it is important to explore the key genes that lead to chronic thrombosis in order to understand the development of CTEPH, and at the same time, it is beneficial to provide new directions for early identification, disease prevention, clinical diagnosis and treatment, and development of novel therapeutic agents. METHODS The GSE130391 dataset was downloaded from the Gene Expression Omnibus (GEO) public database, which includes the full gene expression profiles of patients with CTEPH and Idiopathic Pulmonary Arterial Hypertension (IPAH). Differentially Expressed Genes (DEGs) of CTEPH and IPAH were screened, and then Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) functional enrichment analyses were performed on the DEGs; Weighted Gene Co-Expression Network Analysis (WGCNA) to screen the key gene modules and take the intersection genes of DEGs and the key module genes in WGCNA; STRING database was used to construct the protein-protein interaction (PPI) network; and cytoHubba analysis was performed to identify the hub genes. RESULTS A total of 924 DEGs were screened, and the MEturquoise module with the strongest correlation was selected to take the intersection with DEGs A total of 757 intersecting genes were screened. The top ten hub genes were analyzed by cytoHubba: IL-1B, CXCL8, CCL22, CCL5, CCL20, TNF, IL-12B, JUN, EP300, and CCL4. CONCLUSION IL-1B, CXCL8, CCL22, CCL5, CCL20, TNF, IL-12B, JUN, EP300, and CCL4 have diagnostic and therapeutic value in CTEPH disease, especially playing a role in chronic thrombosis. The discovery of NF-κB, AP-1 transcription factors, and TNF signaling pathway through pivotal genes may be involved in the disease progression process.
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Affiliation(s)
| | - Liu Wang
- Xuzhou Central Hospital, Xuzhou, China
| | | | - Ruoran Li
- Bengbu Medical College, Bengbu, China
- Xuzhou Central Hospital, Xuzhou, China
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12
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Durrington C, Hurdman JA, Elliot CA, Maclean R, Van Veen J, Saccullo G, De-Foneska D, Swift AJ, Smitha R, Hill C, Thomas S, Dwivedi K, Alabed S, Wild JM, Charalampopoulos A, Hameed A, Rothman AMK, Watson L, Hamilton N, Thompson AAR, Condliffe R, Kiely DG. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J 2024; 63:2300846. [PMID: 38302154 PMCID: PMC7615743 DOI: 10.1183/13993003.00846-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. METHODS Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. RESULTS Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. CONCLUSIONS In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.
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Affiliation(s)
- Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Judith A Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rhona Maclean
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joost Van Veen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Giorgia Saccullo
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Duneesha De-Foneska
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Rajaram Smitha
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Krit Dwivedi
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Samer Alabed
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - James M Wild
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Alexander M K Rothman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
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Chia AXF, Valchanov K, Ng C, Tsui S, Taghavi J, Vuylsteke A, Fowles JA, Jenkins DP. Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort. J Heart Lung Transplant 2024; 43:241-250. [PMID: 37730188 DOI: 10.1016/j.healun.2023.09.008] [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: 02/13/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the guideline-recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. METHODS This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected. RESULTS One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for "other" reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. CONCLUSIONS Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.
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Affiliation(s)
- Alicia X F Chia
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Choo Ng
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - John Taghavi
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Alain Vuylsteke
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Jo-Anne Fowles
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom.
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14
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Darie AM. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension - Holy Grail or Holy Trinity? Int J Cardiol 2024; 395:131423. [PMID: 37813284 DOI: 10.1016/j.ijcard.2023.131423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/11/2023]
Affiliation(s)
- Andrei M Darie
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Switzerland
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15
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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16
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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17
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Astashchanka A, Kerr KM, Yang JZ, Bautista A, Papamatheakis DG, Poch DS, Kim NH, Pretorius VG, Madani MM, Fernandes TM. Repeat pulmonary thromboendarterectomy outcomes: A 15-year single-center retrospective review. J Thorac Cardiovasc Surg 2023; 166:1512-1519.e2. [PMID: 37032250 DOI: 10.1016/j.jtcvs.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/24/2023] [Accepted: 02/28/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension is potentially curable via pulmonary thromboendarterectomy. A minority of patients experience recurrence of their symptoms and are eligible for repeat pulmonary thromboendarterectomy. However, little data exist regarding risk factors and outcomes for this patient population. METHODS We performed a retrospective review of the University of California San Diego chronic thromboembolic pulmonary hypertension quality improvement database, including all patients who underwent pulmonary thromboendarterectomy from December 2005 to December 2020. Of the 2019 cases performed during this period, 46 were repeat pulmonary thromboendarterectomy procedures. Demographics, preoperative and postoperative hemodynamics, and surgical complications were compared between the repeat pulmonary thromboendarterectomy group and 1008 first pulmonary thromboendarterectomy group. RESULTS Repeat pulmonary thromboendarterectomy recipients were more likely to be younger, to have an identified hypercoagulable state, and to have higher preoperative right atrial pressure. Etiologies of recurrent disease include incomplete initial endarterectomy, discontinuation of anticoagulation (noncompliance or for medical reasons), and anticoagulation treatment failure. Patients who received repeat pulmonary thromboendarterectomy had significant hemodynamic improvement, but less pronounced compared with patients who received first pulmonary thromboendarterectomy. Repeat pulmonary thromboendarterectomy was associated with an increased risk of postoperative bleeding, reperfusion lung injury, residual pulmonary hypertension, and increased ventilator, intensive care unit, and hospital days. However, hospital mortality was similar between the groups (2.2% vs 1.9%). CONCLUSIONS This is the largest reported series of repeat pulmonary thromboendarterectomy surgery. Despite an increase in postoperative complications, this study demonstrates that repeat pulmonary thromboendarterectomy surgery can result in significant hemodynamic improvement with acceptable surgical mortality in an experienced center.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Kim M Kerr
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Jenny Z Yang
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Angela Bautista
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - David S Poch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, Calif
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, Calif
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif.
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18
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Adameit MSD, Wiedenroth CB, Omlor A, Schäfers HJ, Guth S, Wilkens H. [Chronic thromboembolic pulmonary hypertension]. Dtsch Med Wochenschr 2023; 148:1514-1523. [PMID: 37949080 DOI: 10.1055/a-2012-0899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease, but an important late sequela after acute pulmonary embolism. Therefore, follow-up after at least three months of sufficient anticoagulation is recommended. Patients with suspected CTEPH should be referred to specialized CTEPH centers for further evaluation and treatment.Three treatment modalities are available: pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and pulmonary hypertension-targeted drugs. The indication for surgery depends mainly on the localization of the pulmonary arterial obstructions. Severe comorbidities as well as advanced age need individual evaluation, but do not present strict exclusion criteria. Multimodal treatments are common practice in inoperable CTEPH. However, treatment decision making in an experienced multidisciplinary team is mandatory.
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19
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Guth S, Wilkens H, Halank M, Held M, Hobohm L, Konstantinides S, Omlor A, Seyfarth HJ, Schäfers HJ, Mayer E, Wiedenroth CB. [Chronic thromboembolic pulmonary hypertension]. Pneumologie 2023; 77:937-946. [PMID: 37963483 DOI: 10.1055/a-2145-4807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is an important late complication of acute pulmonary embolism, in which the thrombi transform into fibrous tissue, become integrated into the vessel wall, and lead to chronic obstructions. CTEPD is differentiated into cases without pulmonary hypertension (PH), characterized by a mean pulmonary arterial pressure up to 20 mmHg and a form with PH. Then, it is still referred to as chronic thromboembolic pulmonary hypertension (CTEPH).When there is suspicion of CTEPH, initial diagnostic tests should include echocardiography and ventilation/perfusion scan to detect perfusion defects. Subsequently, referral to a CTEPH center is recommended, where further imaging diagnostics and right heart catheterization are performed to determine the appropriate treatment.Currently, three treatment modalities are available. The treatment of choice is pulmonary endarterectomy (PEA). For non-operable patients or patients with residual PH after PEA, PH-targeted medical therapy, and the interventional procedure of balloon pulmonary angioplasty (BPA) are available. Increasingly, PEA, BPA, and pharmacological therapy are combined in multimodal concepts.Patients require post-treatment follow-up, preferably at (CTE)PH centers. These centers are required to perform a minimum number of PEA surgeries (50/year) and BPA interventions (100/year).
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Affiliation(s)
- Stefan Guth
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Heinrike Wilkens
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin, Missionsärztliche Klinik Würzburg, Würzburg, Deutschland
| | - Lukas Hobohm
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Albert Omlor
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Hans-Jürgen Seyfarth
- Bereich Pneumologie, Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Eckhard Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
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20
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Yang JZ, Poch DS, Ang L, Mahmud E, Kim NH. Balloon pulmonary angioplasty in the current era of CTEPH treatment: How did we get here? Pulm Circ 2023; 13:e12312. [PMID: 38027455 PMCID: PMC10661326 DOI: 10.1002/pul2.12312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved pulmonary embolism. The treatment of choice is pulmonary thromboendarterectomy (PTE) surgery and all patients should be evaluated for operability candidacy. Despite advancements in PTE technique allowing more segmental-subsegmental surgeries, up to a third of patients with CTEPH may still be considered inoperable. Over the past decade, there have been increasing treatment options for these inoperable CTEPH patients. Balloon pulmonary angioplasty (BPA) is a percutaneous-based interventional treatment option for select CTEPH cases. Early BPA experiences were plagued by high complication rates, but further refinements in technique and equipment pioneered by Japan led to the worldwide spread and adoption of BPA. Multiple centers have shown that patients experience significant improvements in hemodynamics, quality of life, exercise capacity, and survival with BPA treatment. There remain many questions on best practices, but BPA has evolved into a pivotal cornerstone of CTEPH treatment.
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Affiliation(s)
- Jenny Z. Yang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
| | - David S. Poch
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Lawrence Ang
- Department of Medicine, Division of Cardiovascular MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Ehtisham Mahmud
- Department of Medicine, Division of Cardiovascular MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Nick H. Kim
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
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21
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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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22
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Wiedenroth CB, Pruefer D, Adameit MSD, Mayer E, Guth S. Chronic thromboembolic pulmonary hypertension-medical, interventional, and surgical therapy. Herz 2023; 48:280-284. [PMID: 37186021 DOI: 10.1007/s00059-023-05172-8] [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] [Accepted: 03/02/2023] [Indexed: 05/17/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an important late sequela of pulmonary embolism and a common form of pulmonary hypertension. Currently, three specific treatment modalities are available: pulmonary endarterectomy, balloon pulmonary angioplasty, and targeted medical therapy. The treatment decision depends mainly on the exact localization of the underlying pulmonary arterial obstructions. Pulmonary endarterectomy is the gold standard treatment of CTEPH. For inoperable patients, riociguat and treprostinil are approved. In addition, interventional therapy is recommended if appropriate target lesions are proven. Evaluation and treatment of patients with CTEPH in experienced centers are mandatory.
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Affiliation(s)
- Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.
| | - Diethard Pruefer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Miriam S D Adameit
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
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23
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Yang J, Madani MM, Mahmud E, Kim NH. Evaluation and Management of Chronic Thromboembolic Pulmonary Hypertension. Chest 2023; 164:490-502. [PMID: 36990148 PMCID: PMC10410247 DOI: 10.1016/j.chest.2023.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension and right heart failure. CTEPH (group 4 pulmonary hypertension) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved acute pulmonary embolism. CTEPH also may present without prior VTE history, which can contribute to its underrecognition. The true incidence of CTEPH is unclear, but is estimated to be approximately 3% after acute pulmonary embolism. V˙/Q˙ scintigraphy is the best screening test for CTEPH, with CT scan imaging and other advanced imaging methods now playing a larger role in disease detection and confirmation. Perfusion defects on V˙/Q˙ scintigraphy in the setting of pulmonary hypertension are suggestive of CTEPH, but pulmonary angiography and right heart catheterization are required for confirmation and treatment planning. CTEPH potentially is curative with pulmonary thromboendarterectomy surgery, with mortality rates of approximately 2% at expert centers. Advances in operative techniques are allowing more distal endarterectomies to be performed successfully with favorable outcomes. However, more than one-third of patients may be considered inoperable. Although these patients previously had minimal therapeutic options, effective treatments now are available with pharmacotherapy and balloon pulmonary angioplasty. Diagnosis of CTEPH should be considered in all patients with suspicion of pulmonary hypertension. Treatments for CTEPH have advanced with improvements in outcomes for both operable and inoperable patients. Therapy should be tailored based on multidisciplinary team evaluation to ensure optimal treatment response.
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Affiliation(s)
- Jenny Yang
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, CA
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA
| | - Nick H Kim
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA.
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24
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Lang IM, Andreassen AK, Andersen A, Bouvaist H, Coghlan G, Escribano-Subias P, Jansa P, Kopec G, Kurzyna M, Matsubara H, Meyer BC, Palazzini M, Post MC, Pruszczyk P, Räber L, Roik M, Rosenkranz S, Wiedenroth CB, Redlin-Werle C, Brenot P. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function. Eur Heart J 2023:ehad413. [PMID: 37470202 PMCID: PMC10393078 DOI: 10.1093/eurheartj/ehad413] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023] Open
Abstract
The current treatment algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) as depicted in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines on the diagnosis and treatment of pulmonary hypertension (PH) includes a multimodal approach of combinations of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapies to target major vessel pulmonary vascular lesions, and microvasculopathy. Today, BPA of >1700 patients has been reported in the literature from centers in Asia, the US, and also Europe; many more patients have been treated outside literature reports. As BPA becomes part of routine care of patients with CTEPH, benchmarks for safe and effective care delivery become increasingly important. In light of this development, the ESC Working Group on Pulmonary Circulation and Right Ventricular Function has decided to publish a document that helps standardize BPA to meet the need of uniformity in patient selection, procedural planning, technical approach, materials and devices, treatment goals, complications including their management, and patient follow-up, thus complementing the guidelines. Delphi methodology was utilized for statements that were not evidence based. First, an anatomical nomenclature and a description of vascular lesions are provided. Second, treatment goals and definitions of complete BPA are outlined. Third, definitions of complications are presented which may be the basis for a standardized reporting in studies involving BPA. The document is intended to serve as a companion to the official ESC/ERS guidelines.
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Pb 4950 Nydalen, 0424 Oslo, Norway
| | - Asger Andersen
- Aarhus University Hospital, Palle Juul Jensens Boulevard 99 8200 Aarhus N Denmark
| | - Helene Bouvaist
- Cardiology Department, Grenoble - Alpes University Hospital, 38043 Grenoble, France
| | - Gerry Coghlan
- Royal Free Hospital, London, Pond Street, Middlesex, London, NW3 2QG
| | | | - Pavel Jansa
- General University Hospital, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Grzegorz Kopec
- Pulmonary Circulation Centre Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka Str. 80, 31-202 Krakow
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology Centre of Postgraduate Medical Education, EHC Otwock, Borowa 14/18, Otwock 05-400, Poland
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Bernhard Christian Meyer
- Medizinische Hochschule Hannover - Institut für Diagnostische und Interventionelle Radiologie Carl-Neuberg-Str. 1, 30625 Hannover
| | - Massimiliano Palazzini
- Dipartimento DIMEC (Dipartimento di Scienze Mediche e Chirurgiche), Università di Bologna, 40126 Bologna, Italy
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern Freiburgstrasse 18 3010 Bern, Switzerland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Stephan Rosenkranz
- Dept. of Cardiology and Cologne Cardiovascular Research Center, Heart Center at the University Hospital Cologne, Kerpener Str. 62, 50937 Köln, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Carlo Redlin-Werle
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Philippe Brenot
- Interventional Radiology Department, Marie Lannelongue Hospital, Le Plessis Robinson 92350 France
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25
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Wiedenroth CB, Mayer E, Guth S. Therapie der chronisch thromboembolischen pulmonalen Hypertonie. AKTUELLE KARDIOLOGIE 2023. [DOI: 10.1055/a-1953-5670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
ZusammenfassungDie chronisch thromboembolische pulmonale Hypertonie (CTEPH) ist eine wichtige und oft gut behandelbare Form der pulmonalen Hypertonie. Es stehen aktuell 3 Therapiemodalitäten zur
Verfügung: die pulmonale Endarteriektomie, die pulmonale Ballonangioplastie und die gezielte medikamentöse Behandlung. Das therapeutische Konzept hängt maßgeblich von der Lokalisation der
zugrunde liegenden pulmonalarteriellen fibrösen Obstruktionen ab. Die pulmonale Endarteriektomie ist der Goldstandard in der Behandlung der CTEPH. Für inoperable Patienten stehen
mittlerweile 2 zugelassene Substanzen (Riociguat und Treprostinil) zur Verfügung. Daneben wird bei Vorhandensein entsprechender Zielgebiete die interventionelle Therapie empfohlen.
Evaluation und Behandlung von CTEPH-Patienten sollte in entsprechend erfahrenen Zentren erfolgen.
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Affiliation(s)
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Klinik GmbH, Bad Nauheim, Deutschland
| | - Stefan Guth
- Thoracic Surgery, Kerckhoff Klinik GmbH, Bad Nauheim, Deutschland
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26
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Mahdi N, Nadeem I, Ur Rasool M, Ul Munamm SA, Khatana UF, Rashad F, Babu A. Pulmonary hypertension due to pulmonary embolism secondary to COVID-19: A district general hospital experience from the UK. J R Coll Physicians Edinb 2023; 53:9-12. [PMID: 36705094 PMCID: PMC9884629 DOI: 10.1177/14782715231152677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Preliminary data suggest that the prevalence of pulmonary hypertension (PH) in patients with COVID-19 is around 13%, but its prognostic role remains unclear. Approximately 3% of patients develop chronic thrombo-embolic pulmonary hypertension (CTEPH) following diagnosis of acute pulmonary embolism (PE). It is recommended that patients are screened for CTEPH if they remain symptomatic 3 months following diagnosis of PE. AIMS The primary aim of the study was to assess the chances of persistent PH following PE secondary to COVID-19. METHODS We conducted a retrospective cohort study at a District General Hospital (DGH) in the United Kingdom. All patients diagnosed with COVID-19 and PE between April 2020 and October 2021 were examined. Patients were divided into two groups:·COVID-19 and PE with comorbidities (excluding pre-existing PH) and·COVID-19 and PE without comorbidities. We compared the ECHO features suggestive of PH between the two groups at the time of diagnosis of PE and at 3 months following treatment. RESULTS 80 patients were included in the study (49 with comorbidities and 31 with no comorbidities). Average age of comorbidities and no comorbidities groups were 73 years and 70 years, respectively. Average PaO2/FiO2 ratio for comorbidities and no comorbidities groups were 170 and 195, respectively. Fourteen patients (13 with comorbidities and 1 with no comorbidities) died in total. Results showed that risk of persistent PH and subsequent mortality following PE in COVID19 is 4.17 times and 1.32 times more in comorbidity group as compared to no comorbidity group, respectively (p < 0.001). CONCLUSION Patients with comorbidities are at high risk of persistent PH and mortality due to PE secondary to COVID19.
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Affiliation(s)
- Noor Mahdi
- Royal Papworth Hospital NHS Trust,
Cambridge, UK
| | - Iftikhar Nadeem
- Royal Papworth Hospital NHS Trust,
Cambridge, UK,Iftikhar Nadeem, Royal Papworth Hospital
NHS Trust, Cambridge, UK.
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27
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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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28
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J 2023; 61:13993003.00879-2022. [PMID: 36028254 DOI: 10.1183/13993003.00879-2022] [Citation(s) in RCA: 517] [Impact Index Per Article: 517.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Marc Humbert
- Faculty of Medicine, Université Paris-Saclay, Le Kremlin-Bicêtre, France, Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Gabor Kovacs
- University Clinic of Internal Medicine, Division of Pulmonology, Medical University of Graz, Graz, Austria
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Marius M Hoeper
- Respiratory Medicine, Hannover Medical School, Hanover, Germany
- Biomedical Research in End-stage and Obstructive Lung Disease (BREATH), member of the German Centre of Lung Research (DZL), Hanover, Germany
| | - Roberto Badagliacca
- Dipartimento di Scienze Cliniche Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Roma, Italy
- Dipartimento Cardio-Toraco-Vascolare e Chirurgia dei Trapianti d'Organo, Policlinico Umberto I, Roma, Italy
| | - Rolf M F Berger
- Center for Congenital Heart Diseases, Beatrix Children's Hospital, Dept of Paediatric Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Margarita Brida
- Department of Sports and Rehabilitation Medicine, Medical Faculty University of Rijeka, Rijeka, Croatia
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton and Harefield Hospitals, Guys and St Thomas's NHS Trust, London, UK
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andrew J S Coats
- Faculty of Medicine, University of Warwick, Coventry, UK
- Faculty of Medicine, Monash University, Melbourne, Australia
| | - Pilar Escribano-Subias
- Pulmonary Hypertension Unit, Cardiology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
- CIBER-CV (Centro de Investigaciones Biomédicas En Red de enfermedades CardioVasculares), Instituto de Salud Carlos III, Madrid, Spain
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Pisana Ferrari
- ESC Patient Forum, Sophia Antipolis, France
- AIPI, Associazione Italiana Ipertensione Polmonare, Bologna, Italy
| | - Diogenes S Ferreira
- Alergia e Imunologia, Hospital de Clinicas, Universidade Federal do Parana, Curitiba, Brazil
| | - Hossein Ardeschir Ghofrani
- Department of Internal Medicine, University Hospital Giessen, Justus-Liebig University, Giessen, Germany
- Department of Pneumology, Kerckhoff Klinik, Bad Nauheim, Germany
- Department of Medicine, Imperial College London, London, UK
| | - George Giannakoulas
- Cardiology Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
| | - Eckhard Mayer
- Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Gergely Meszaros
- ESC Patient Forum, Sophia Antipolis, France
- European Lung Foundation (ELF), Sheffield, UK
| | - Blin Nagavci
- Institute for Evidence in Medicine, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Karen M Olsson
- Clinic of Respiratory Medicine, Hannover Medical School, member of the German Center of Lung Research (DZL), Hannover, Germany
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, UK
| | | | - Göran Rådegran
- Department of Cardiology, Clinical Sciences Lund, Faculty of Medicine, Lund, Sweden
- The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerald Simonneau
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Centre de Référence de l'Hypertension Pulmonaire, Hopital Marie-Lannelongue, Le Plessis-Robinson, France
| | - Olivier Sitbon
- INSERM UMR_S 999, Hôpital Marie-Lannelongue, Le Plessis-Robinson, France
- Faculté Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France
- Service de Pneumologie et Soins Intensifs Respiratoires, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Mark Toshner
- Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Royal Papworth NHS Trust, Cambridge, UK
| | - Jean-Luc Vachiery
- Department of Cardiology, Pulmonary Vascular Diseases and Heart Failure Clinic, HUB Hôpital Erasme, Brussels, Belgium
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Centre of Pulmonary Vascular Diseases, University Hospitals of Leuven, Leuven, Belgium
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine (Department of Cardiology, Pulmonology and Intensive Care Medicine), and Cologne Cardiovascular Research Center (CCRC), Heart Center at the University Hospital Cologne, Köln, Germany
- The two chairpersons (M. Delcroix and S. Rosenkranz) contributed equally to the document and are joint corresponding authors
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Song W, Zhu J, Zhong Z, Song Y, Liu S. Long-term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy. Clin Cardiol 2022; 45:1255-1263. [PMID: 36070474 DOI: 10.1002/clc.23900] [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: 05/23/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), which has good long-term outcomes. However, after surgery, a quarter of the patients still have residual pulmonary hypertension (RPH). In pulmonary hemodynamics, there are no unified criteria for RPH, even though the level may affect long-term survival. METHODS Between March 1997 and December 2021, 253 CTEPH patients were treated at our center with PEA. Patients were evaluated retrospectively and classified into early (1997-2014) and late (2015-2021) groups. The clinical characteristics and perioperative outcomes of the two groups were compared, and risk factor analysis for RPH and long-term survival for all cases was performed. RESULTS There was no statistically significant difference in demographics between the two groups. However, the Early Group had a significantly higher rate of perioperative death (9.8% vs. 1.2%, p = .001), RPH (48.8% vs. 14.0%, p < .001), and reperfusion pulmonary edema (18.3% vs. 2.9%, p < .001). The median follow-up time was 66.0 months, and overall survival rates at 5, 10, 15, and 18 years after PEA were 91.2%, 83.9%, 64.5%, and 46.0%, respectively. Age and postoperative systolic pulmonary artery pressure (sPAP) were independently related to long-term outcomes in the multivariate Cox analyses. Patients with postoperative sPAP less than 46 mm Hg had a higher chance of survival. CONCLUSIONS PEA improved CTEPH hemodynamics immediately and had a positive effect on long-term survival. Patients with postoperative sPAP ≥ 46 mm Hg indicate clinically significant RPH and have a lower long-term survival rate.
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Affiliation(s)
- Wu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiade Zhu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - ZhaoJi Zhong
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yunhu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Faccioli E, Verzeletti V, Perazzolo Marra M, Boscolo A, Schiavon M, Navalesi P, Rea F, Dell’Amore A. Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review of the Most Updated Literature. J Clin Med 2022; 11:jcm11236976. [PMID: 36498551 PMCID: PMC9738233 DOI: 10.3390/jcm11236976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice in case of chronic thromboembolic pulmonary hypertension (CTEPH). PEA is performed by an increasing number of surgeons; however, the reported outcomes are limited to a few registries or to individual centers' experiences. This systematic review focuses on pre-operative evaluation, intra-operative procedure and post-operative results in patients submitted to PEA for CTEPH. The literature included was searched using a formal strategy, combining the terms "pulmonary endarterectomy" AND "chronic pulmonary hypertension" and focusing on studies published in the last 5 years (2017-2022) to give a comprehensive overview on the most updated literature. The selection of the adequate surgical candidate is a crucial point, and the decision should always be performed by expert multidisciplinary teams composed of surgeons, pulmonologists and radiologists. In all the included studies, the surgical procedure was performed through a median sternotomy with intermittent deep hypothermic circulatory arrest under cardiopulmonary bypass. In case of residual pulmonary hypertension, alternative combined treatments should be considered (balloon angioplasty and/or medical therapy until lung transplantation in highly selected cases). Short- and long-term outcomes, although not homogenous across the different studies, are acceptable in highly experienced CTEPH centers.
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Affiliation(s)
- Eleonora Faccioli
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | | | | | - Annalisa Boscolo
- Intensive Care Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Paolo Navalesi
- Intensive Care Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Federico Rea
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Andrea Dell’Amore
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
- Correspondence:
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Miao R, Dong X, Gong J, Li Y, Guo X, Wang J, Huang Q, Wang Y, Li J, Yang S, Kuang T, Liu M, Wan J, Zhai Z, Zhong J, Yang Y. Single-cell RNA-sequencing and microarray analyses to explore the pathological mechanisms of chronic thromboembolic pulmonary hypertension. Front Cardiovasc Med 2022; 9:900353. [PMID: 36440052 PMCID: PMC9684175 DOI: 10.3389/fcvm.2022.900353] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 10/21/2022] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE The present study aimed to explore the pathological mechanisms of chronic thromboembolic pulmonary hypertension (CTEPH) using a gene chip array and single-cell RNA-sequencing (scRNA-seq). MATERIALS AND METHODS The mRNA expression profile GSE130391 was downloaded from the Gene Expression Omnibus database. The peripheral blood samples of five CTEPH patients and five healthy controls were used to prepare the Affymetrix microRNA (miRNA) chip and the Agilent circular RNA (circRNA) chip. The pulmonary endarterectomized tissues from five CTEPH patients were analyzed by scRNA-seq. Cells were clustered and annotated, followed by the identification of highly expressed genes. The gene chip data were used to identify disease-related mRNAs and differentially expressed miRNAs and circRNAs. The protein-protein interaction (PPI) network and the circRNA-miRNA-mRNA network were constructed for each cell type. RESULTS A total of 11 cell types were identified. Intersection analysis of highly expressed genes in each cell type and differentially expressed mRNAs were performed to obtain disease-related genes in each cell type. TP53, ICAM1, APP, ITGB2, MYC, and ZYX showed the highest degree of connectivity in the PPI network of different types of cells. In addition, the circRNA-miRNA-mRNA network for each cell type was constructed. CONCLUSION For the first time, the key mRNAs, miRNAs, and circRNAs, as well as their possible regulatory relationships, during the progression of CTEPH were analyzed using both gene chip and scRNA-seq data. These findings may contribute to a better understanding of the pathological mechanisms of CTEPH.
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Affiliation(s)
- Ran Miao
- Medical Research Center, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xingbei Dong
- Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juanni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Echocardiography, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiaojuan Guo
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Wang
- Department of Interventional Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Qiang Huang
- Department of Interventional Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Ying Wang
- Department of Pathology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jifeng Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Suqiao Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Tuguang Kuang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, Beijing, China
| | - Jun Wan
- Department of Respiration, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Jiuchang Zhong
- Heart Center and Beijing Key Laboratory of Hypertension, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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Shahin Y, Alabed S, Alkhanfar D, Tschirren J, Rothman AMK, Condliffe R, Wild JM, Kiely DG, Swift AJ. Quantitative CT Evaluation of Small Pulmonary Vessels Has Functional and Prognostic Value in Pulmonary Hypertension. Radiology 2022; 305:431-440. [PMID: 35819325 PMCID: PMC9619204 DOI: 10.1148/radiol.210482] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/21/2022] [Accepted: 05/05/2022] [Indexed: 11/11/2022]
Abstract
Background The in vivo relationship between peel pulmonary vessels, small pulmonary vessels, and pulmonary hypertension (PH) is not fully understood. Purpose To quantitatively assess peel pulmonary vessel volumes (PPVVs) and small pulmonary vessel volumes (SPVVs) as estimated from CT pulmonary angiography (CTPA) in different subtypes of PH compared with controls, their relationship to pulmonary function and right heart catheter metrics, and their prognostic value. Materials and Methods In this retrospective single-center study performed from January 2008 to February 2018, quantitative CTPA analysis of total SPVV (TSPVV) (0.4- to 2-mm vessel diameter) and PPVV (within 15, 30, and 45 mm from the lung surface) was performed. Results A total of 1823 patients (mean age, 69 years ± 13 [SD]; 1192 women [65%]) were retrospectively analyzed; 1593 patients with PH (mean pulmonary arterial pressure [mPAP], 43 mmHg ± 13 [SD]) were compared with 230 patient controls (mPAP, 19 mm Hg ± 3). The mean vessel volumes in pulmonary peels at 15-, 30-, and 45-mm depths were higher in pulmonary arterial hypertension (PAH) and PH secondary to lung disease compared with chronic thromboembolic PH (45-mm peel, mean difference: 6.4 mL [95% CI: 1, 11] [P < .001] vs 6.8 mL [95% CI: 1, 12] [P = .01]). Mean small vessel volumes at a diameter of less than 2 mm were lower in PAH and PH associated with left heart disease compared with controls (1.6-mm vessels, mean difference: -4.3 mL [95% CI: -8, -0.1] [P = .03] vs -6.8 mL [95% CI: -11, -2] [P < .001]). In patients with PH, the most significant positive correlation was noted with forced vital capacity percentage predicted (r = 0.30-0.40 [all P < .001] for TSPVVs and r = 0.21-0.25 [all P < .001] for PPVVs). Conclusion The volume of pulmonary small vessels is reduced in pulmonary arterial hypertension and pulmonary hypertension (PH) associated with left heart disease, with similar volume of peel vessels compared with controls. For chronic thromboembolic PH, the volume of peel vessels is reduced. In PH, small pulmonary vessel volume is associated with pulmonary function tests. Clinical trial registration no. NCT02565030 Published under a CC BY 4.0 license Online supplemental material is available for this article.
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Affiliation(s)
- Yousef Shahin
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Samer Alabed
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Dheyaa Alkhanfar
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Juerg Tschirren
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Alex M. K. Rothman
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Robin Condliffe
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - James M. Wild
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - David G. Kiely
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
| | - Andrew J. Swift
- From the Department of Infection, Immunity and Cardiovascular Disease
(Y.S., S.A., D.A., A.M.K.R., J.M.W., D.G.K., A.J.S.) and INSIGNEO, Institute for
in silico Medicine (D.G.K., A.J.S.), University of Sheffield, Glossop Rd,
Sheffield S10 2JF, England; Department of Clinical Radiology, Sheffield
Teaching Hospitals, Sheffield, England (Y.S., S.A., A.J.S.); VIDA Diagnostics,
Coralville, Iowa (J.T.); and Sheffield Pulmonary Vascular Disease Unit, Royal
Hallamshire Hospital, Sheffield, England (R.C., D.G.K.)
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Jansa P, Ambrož D, Aschermann M, Černý V, Dytrych V, Heller S, Kunstýř J, Lindner J, Linhart A, Nižnanský M, Paďour M, Prskavec T, Širanec M, Edwards S, Gressin V, Kuhn M, Di Scala L. Hospitalisation Is Prognostic of Survival in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 11:jcm11206189. [PMID: 36294508 PMCID: PMC9605547 DOI: 10.3390/jcm11206189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/04/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
This analysis investigated the prognostic value of hospitalisation in chronic thromboembolic pulmonary hypertension (CTEPH) using data from the Czech Republic, wherein pulmonary endarterectomy (PEA) was the only targeted treatment option until 2015. Using a landmark method, this analysis quantified the association between a first CTEPH-related hospitalisation event occurring before 3-, 6-, 9-, and 12-month landmark timepoints and subsequent all-cause mortality in adult CTEPH patients diagnosed between 2003 and 2016 in the Czech Republic. Patients were stratified into operable and inoperable, according to PEA eligibility. CTEPH-related hospitalisations were defined as non-elective. Hospitalisations related to CTEPH diagnosis, PEA, balloon pulmonary angioplasty, or clinical trial participation were excluded. Of 436 patients who survived to ≥3 months post diagnosis, 309 were operable, and 127 were inoperable. Sex- and age-adjusted hazard ratios (HRs) showed CTEPH-related hospitalisation was a statistically significant prognostic indicator of mortality at 3, 9, and 12 months in inoperable patients, with an approximately 2-fold increased risk of death in the hospitalisation group (HRs [95% CI] ranging from 1.98 [1.06–3.70] to 2.17 [1.01–4.63]). There was also a trend of worse survival probabilities in the hospitalisation groups for operable patients, with the difference most pronounced at 3 months, with a 76% increased risk of death (adjusted HR [95% CI] 1.76 [1.15–2.68]). This first analysis on the prognostic value of CTEPH-related hospitalisations demonstrates that a first CTEPH-related hospitalisation is prognostic of mortality in CTEPH, particularly for inoperable patients. These patients may benefit from medical and/or interventional therapy.
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Affiliation(s)
- Pavel Jansa
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
- Correspondence: ; Tel.: +420-728-717-041
| | - David Ambrož
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Michael Aschermann
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Vladimír Černý
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Vladimír Dytrych
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Samuel Heller
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Jan Kunstýř
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Jaroslav Lindner
- 2nd Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Aleš Linhart
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Matúš Nižnanský
- 2nd Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Michal Paďour
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Tomáš Prskavec
- 2nd Department of Surgery, Department of Cardiovascular Surgery, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Michal Širanec
- 2nd Department of Internal Medicine–Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, 128 08 Prague, Czech Republic
| | - Susan Edwards
- Actelion Pharmaceuticals Ltd., A Janssen Pharmaceutical Company of Johnson & Johnson, 4123 Allschwil, Switzerland
| | - Virginie Gressin
- Actelion Pharmaceuticals Ltd., A Janssen Pharmaceutical Company of Johnson & Johnson, 4123 Allschwil, Switzerland
| | - Matyáš Kuhn
- Data Analysis Department, Institute of Biostatistics and Analysis Ltd., 602 00 Brno, Czech Republic
| | - Lilla Di Scala
- Actelion Pharmaceuticals Ltd., A Janssen Pharmaceutical Company of Johnson & Johnson, 4123 Allschwil, Switzerland
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Humbert M, Kovacs G, Hoeper MM, Badagliacca R, Berger RMF, Brida M, Carlsen J, Coats AJS, Escribano-Subias P, Ferrari P, Ferreira DS, Ghofrani HA, Giannakoulas G, Kiely DG, Mayer E, Meszaros G, Nagavci B, Olsson KM, Pepke-Zaba J, Quint JK, Rådegran G, Simonneau G, Sitbon O, Tonia T, Toshner M, Vachiery JL, Vonk Noordegraaf A, Delcroix M, Rosenkranz S. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J 2022; 43:3618-3731. [PMID: 36017548 DOI: 10.1093/eurheartj/ehac237] [Citation(s) in RCA: 1170] [Impact Index Per Article: 585.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Fu Z, Tao X, Xie W, Yang P, Gao Q, Wang J, Zhai Z. Different response of the oxygen pathway in patients with chronic thromboembolic pulmonary hypertension treated with pulmonary endarterectomy versus balloon pulmonary angioplasty. Front Cardiovasc Med 2022; 9:990207. [PMID: 36237910 PMCID: PMC9551285 DOI: 10.3389/fcvm.2022.990207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/31/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundOxygen pathway limitation exists in chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) are two effective interventions for CTEPH, but their effects and comparison of these two interventions on the oxygen pathway are not well demonstrated.MethodsCTEPH patients with available pulmonary function test, hemodynamics, and blood gas analysis before and after the interventions were included for comparison of oxygen pathway in terms of lung ventilation, lung gas exchange, oxygen delivery, and oxygen extraction between these two interventions.ResultsThe change in the percentage of the predicted forced expiratory volume in the 1 s (−3.4 ± 12.7 vs. 3.8 ± 8.7%, P = 0.006) and forced vital capacity (−5.5 ± 13.0 vs. 4.2 ± 9.9%, P = 0.001) among the PEA group (n = 24) and BPA group (n = 46) were significantly different. Patients in the PEA group had a significant increase in their arterial oxygen saturation (from 92.5 ± 3.6 to 94.6 ± 2.4%, P = 0.022), while those in the BPA group had no change, which could be explained by a significant improvement in ventilation/perfusion (−0.48 ± 0.53 vs. −0.17 ± 0.41, P = 0.016). Compared with patients post-BPA, patients post-PEA were characterized by higher oxygen delivery (756.3 ± 229.1 vs. 628.8 ± 188.5 ml/min, P = 0.016) and higher oxygen extraction (203.3 ± 64.8 vs. 151.2 ± 31.9 ml/min, P = 0.001).ConclusionPartial amelioration of the oxygen pathway limitations could be achieved in CTEPH patients treated with PEA and BPA. CTEPH patients post-PEA had better performance in lung gas exchange, oxygen delivery, and extraction, while those post-BPA had better lung ventilation. Cardiopulmonary rehabilitation may assist in improving the impairment of the oxygen pathway.
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Affiliation(s)
- Zhihui Fu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
- Department of Pulmonary and Critical Care Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China
| | - Xincao Tao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Wanmu Xie
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Peiran Yang
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- State Key Laboratory of Medical Molecular Biology, Department of Physiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
| | - Qian Gao
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
| | - Jinzhi Wang
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- National Center for Respiratory Medicine, Beijing, China
- Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Beijing, China
- National Clinical Research Center for Respiratory Diseases, Beijing, China
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing, China
- *Correspondence: Zhenguo Zhai,
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36
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Kjellström B, Bouzina H, Björklund E, Beaudet A, Edwards SC, Hesselstrand R, Jansson K, Nisell M, Rådegran G, Sandqvist A, Wåhlander H, Hjalmarsson C, Söderberg S. Five year risk assessment and treatment patterns in patients with chronic thromboembolic pulmonary hypertension. ESC Heart Fail 2022; 9:3264-3274. [PMID: 35789127 DOI: 10.1002/ehf2.14033] [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: 01/26/2022] [Revised: 04/20/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Repeated risk assessments and treatment patterns over long time are sparsely studied in chronic thromboembolic pulmonary hypertension (CTEPH); thus, we aimed to investigate changes in risk status and treatment patterns in incident patients with CTEPH over a 5 year period. METHODS AND RESULTS Descriptive and explorative study including 311 patients diagnosed with CTEPH 2008-2019 from the Swedish pulmonary hypertension registry, stratified by pulmonary endarterectomy surgery (PEA). Risk and PH-specific treatment were assessed in surgically treated (PEA) and medically treated (non-PEA) patients at diagnosis and up to 5 years follow-up. Data are presented as median (Q1-Q3), count or per cent. Prior to surgery, 63% in the PEA-group [n = 98, age 64 (51-71) years, 37% female] used PH-specific treatment and 20, 69, and 10% were assessed as low, intermediate or high risk, respectively. After 1 year post-surgery, 34% had no PH-specific treatment or follow-up visit registered despite being alive at 5 years. Of patients with a 5 year visit (n = 23), 46% were at low and 54% at intermediate risk, while 91% used PH-specific treatment. In the non-PEA group [n = 213, age 72 (65-77) years, 56% female], 28% were assessed as low, 61% as intermediate and 11% as high risk. All patients at high risk versus 50% at low risk used PH-specific treatment. The 1 year mortality was 6%, while the risk was unchanged in 57% of the patients; 14% improved from intermediate to low risk, and 1% from high to low risk. At 5 years, 27% had a registered visit and 28% had died. Of patients with a 5 year visit (n = 58), 38% were at low, 59% at intermediate and 1% at high risk, and 86% used PH-specific treatment. CONCLUSIONS Risk status assessed pre-surgery did not foresee long-term post-PEA risk and pre-surgery PH-specific treatment did not foresee long-term post-PEA treatment. Medically treated CTEPH patients tend to remain at the same risk over time, suggesting a need for improved treatment strategies in this group.
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Affiliation(s)
- Barbro Kjellström
- Lund University, Department of Clinical Sciences Lund, Clinical Physiology and Skåne University Hospital, Lund, Sweden.,Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Habib Bouzina
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden
| | - Erik Björklund
- Department of Cardiology, University Hospital, Uppsala, Sweden
| | | | | | - Roger Hesselstrand
- Department of Clinical Sciences Lund, Section for Rheumatology, Lund University and Skåne university hospital, Lund, Sweden
| | - Kjell Jansson
- Department of Cardiology and Department of Clinical Physiology Institution of Medicine and Health Science, Linköping University, Linköping, Sweden
| | - Magnus Nisell
- Lung Unit, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Haemodynamic Lab, The Section for Heart Failure and Valvular Disease, VO. Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | | | - Håkan Wåhlander
- Pediatric Heart Center, The Queen Silvia Children's Hospital, Sahlgrenska University Hospital, and Department of Pediatrics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Clara Hjalmarsson
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, Medicine Unit, Umeå University, Umeå, Sweden
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37
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van Uden D, Koudstaal T, van Hulst JAC, van den Bosch TPP, Vink M, Bergen IM, Lila KA, van den Bosch AE, Bresser P, Kool M, von der Thüsen JH, Hendriks RW, Boomars KA. Evidence for a Role of CCR6+ T Cells in Chronic Thromboembolic Pulmonary Hypertension. Front Immunol 2022; 13:861450. [PMID: 35572511 PMCID: PMC9094486 DOI: 10.3389/fimmu.2022.861450] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/29/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Previous studies have shown an increase of T cells and chemokines in vascular lesions of patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, detailed characterization of these T cells is still lacking, nor have treatment effects been evaluated. Methods We included 41 treatment-naive CTEPH patients at diagnosis, 22 patients at 1-year follow-up, and 17 healthy controls (HCs). Peripheral blood T cells were characterized by flow cytometry for subset distribution, cytokine expression and activation marker profile. We used multiplex immunofluorescence to identify CCR6+ T cells in endarterectomy tissue from 25 patients. Results At diagnosis, proportions of CCR6+ CD4+ T cells were increased in CTEPH patients compared with HCs. Patients displayed a significantly reduced production capacity of several cytokines including TNFα, IFNγ, GM-CSF and IL-4 in CD4+ T cells, and TNFα and IFNγ in CD8+ T cells. CD4+ and CD8+ T cells showed increased expression of the immune checkpoint protein CTLA4. Multivariate analysis separated CTEPH patients from HCs, based on CCR6 and CTLA4 expression. At 1-year follow-up, proportions of CCR6+CD4+ T cells were further increased, IFNγ and IL-17 production capacity of CD4+ T cells was restored. In nearly all vascular lesions we found substantial numbers of CCR6+ T cells. Conclusion The observed increase of CCR6+ T cells and modulation of the IFNγ and IL-17 production capacity of circulating CD4+ T cells at diagnosis and 1-year follow-up – together with the presence of CCR6+ T cells in vascular lesions - support the involvement of the Th17-associated CCR6+ T cell subset in CTEPH.
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Affiliation(s)
- Denise van Uden
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Thomas Koudstaal
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennifer A C van Hulst
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Madelief Vink
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Ingrid M Bergen
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Karishma A Lila
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Annemien E van den Bosch
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Paul Bresser
- Department of Respiratory Medicine, OLVG, Amsterdam, Netherlands
| | - Mirjam Kool
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jan H von der Thüsen
- Department of Pathology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Rudi W Hendriks
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Karin A Boomars
- Department of Pulmonary Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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38
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Tyler Artner
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
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39
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Verbelen T, Godinas L, Maleux G, Coolen J, Claessen G, Belge C, Meyns B, Delcroix M. Chronic thromboembolic pulmonary hypertension: diagnosis, operability assessment and patient selection for pulmonary endarterectomy. Ann Cardiothorac Surg 2022; 11:82-97. [PMID: 35433370 PMCID: PMC9012197 DOI: 10.21037/acs-2021-pte-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 07/30/2023]
Abstract
Healthcare providers outside pulmonary hypertension (PH) centers having misinformation or insufficient education, and a general lack of treatment awareness contribute to a massive underdiagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), diagnostic delay and refusal of surgery by patients. Together with the subjective operability assessment, this leads to too few patients undergoing pulmonary endarterectomy (PEA); even though this surgery results in improved survival and exercise capacity. Acute pulmonary embolism (PE) survivors should undergo a CTEPH screening strategy. Patients screened positive and those with CTEPH symptoms (with or without history of PE), should undergo transthoracic echocardiography (TTE) to determine the probability of PH. High PH probability patients should undergo a ventilation/perfusion (V/Q) scan. A negative scan rules out CTEPH. Patients with a positive V/Q scan, but also patients with findings suggestive for CTEPH on computed tomography pulmonary angiography (CTPA) to diagnose acute PE, should be referred to a CTEPH center. Further diagnostic work-up currently consists of catheter based pulmonary angiography, CTPA and right heart catheterization. However, new imaging technologies might replace them in the near future, with one single imaging tool to screen, diagnose and assess operability as the ultimate goal. Operability assessment should be performed by a multidisciplinary CTEPH team. PEA surgery should be organized in a single center per country or for each forty to fifty million inhabitants in order to offer the highest level of expertise. Informing patients about PEA should preferably be done by the treating surgeon. Based on the estimated incidence of CTEPH and with a better education of patients and healthcare providers, despite the advent of new interventional and medical therapies for CTEPH, the number of PEA surgeries performed should still have the potential to grow significantly.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurent Godinas
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Coolen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Catharina Belge
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
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40
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Cannon JE, Jenkins DP, Hoole SP. Chronic thromboembolic pulmonary hypertension: a review of risk factors, management and current challenges. Expert Rev Cardiovasc Ther 2022; 20:35-43. [DOI: 10.1080/14779072.2022.2034499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- JE Cannon
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge, UK
| | - DP Jenkins
- Cardiothoracic Surgical Unit, Royal Papworth Hospital, Cambridge, UK
| | - SP Hoole
- Interventional Cardiology, Royal Papworth Hospital, Cambridge, UK
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41
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Shahin Y, Alabed S, Rehan Quadery S, Lewis RA, Johns C, Alkhanfar D, Sukhanenko M, Alandejani F, Garg P, Elliot CA, Hameed A, Charalampopoulos A, Wild JM, Condliffe R, Swift AJ, Kiely DG. CMR Measures of Left Atrial Volume Index and Right Ventricular Function Have Prognostic Value in Chronic Thromboembolic Pulmonary Hypertension. Front Med (Lausanne) 2022; 9:840196. [PMID: 35360708 PMCID: PMC8964043 DOI: 10.3389/fmed.2022.840196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/04/2022] [Indexed: 11/13/2022] Open
Abstract
Providing prognostic information is important when counseling patients and planning treatment strategies in chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to assess the prognostic value of gold standard imaging of cardiac structure and function using cardiac magnetic resonance imaging (CMR) in CTEPH. Consecutive treatment-naive patients with CTEPH who underwent right heart catheterization and CMR between 2011 and 2017 were identified from the ASPIRE (Assessing-the-Specturm-of-Pulmonary-hypertensIon-at-a-REferral-center) registry. CMR metrics were corrected for age and sex where appropriate. Univariate and multivariate regression models were generated to assess the prognostic ability of CMR metrics in CTEPH. Three hundred and seventy-five patients (mean+/-standard deviation: age 64+/-14 years, 49% female) were identified and 181 (48%) had pulmonary endarterectomy (PEA). For all patients with CTEPH, left-ventricular-stroke-volume-index-%predicted (LVSVI%predicted) (p = 0.040), left-atrial-volume-index (LAVI) (p = 0.030), the presence of comorbidities, incremental shuttle walking test distance (ISWD), mixed venous oxygen saturation and undergoing PEA were independent predictors of mortality at multivariate analysis. In patients undergoing PEA, LAVI (p < 0.010), ISWD and comorbidities and in patients not undergoing surgery, right-ventricular-ejection-fraction-%predicted (RVEF%pred) (p = 0.040), age and ISWD were independent predictors of mortality. CMR metrics reflecting cardiac function and left heart disease have prognostic value in CTEPH. In those undergoing PEA, LAVI predicts outcome whereas in patients not undergoing PEA RVEF%pred predicts outcome. This study highlights the prognostic value of imaging cardiac structure and function in CTEPH and the importance of considering left heart disease in patients considered for PEA.
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Affiliation(s)
- Yousef Shahin
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Department of Clinical Radiology, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Department of Clinical Radiology, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Syed Rehan Quadery
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Robert A Lewis
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Christopher Johns
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Dheyaa Alkhanfar
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Maria Sukhanenko
- Department of Clinical Radiology, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Faisal Alandejani
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Abdul Hameed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Athaniosis Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - James M Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Department of Clinical Radiology, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom.,INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - David G Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS FT, Sheffield, United Kingdom.,INSIGNEO, Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
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42
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Diamanti E, Karava V, Yerly P, Aubert JD. Carbon Monoxide Diffusion Capacity as a Severity Marker in Pulmonary Hypertension. J Clin Med 2021; 11:jcm11010132. [PMID: 35011871 PMCID: PMC8745155 DOI: 10.3390/jcm11010132] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/22/2021] [Accepted: 12/23/2021] [Indexed: 01/09/2023] Open
Abstract
Carbon monoxide diffusion capacity (DLCO) is negatively associated with patient survival in idiopathic pulmonary hypertension (PH), but is not included in the risk stratification score proposed by the 2015 European guidelines. Since 2015, several new stratification scores based on a 3- or 4-severity scale have been explored. This retrospective cohort single-center study sought to investigate the association between DLCO and PH severity and survival. We included 85 treatment-naive patients with precapillary PH and DLCO measurement at diagnosis. DLCO status, based on lower and upper quartiles ranges, was added to a 3- and a 4-strata modified-risk assessment. DLCO was strongly associated with transplant-free survival (HR 0.939, 95% CI: 0.908–0.971, p < 0.001). In the intermediate and high-risk categories, DLCO was associated with transplant-free survival, irrespective of the risk category (HR 0.934, 95% CI: 0.880–0.980, p = 0.005). The correlation between modified-risk category and transplant-free survival was significant (HR 4.60, 95% CI: 1.294–16.352, p = 0.018). Based on the Akaike information criterion (AIC) levels, the 3- and 4-strata modified-risk stratification fits our results better than the conventional stratification. Low DLCO is associated with patient transplant-free survival, independently of the risk category. Inclusion of DLCO into a PH risk stratification score seems promising and needs further investigation.
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Affiliation(s)
- Eleni Diamanti
- Division of Pulmonology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - Vasiliki Karava
- 1st Department of Pediatrics, Aristotle University of Thessaloniki, 541 24 Thessaloniki, Greece;
| | - Patrick Yerly
- Division of Cardiology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - John David Aubert
- Division of Pulmonology, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
- Correspondence:
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43
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Boon GJAM, van den Hout WB, Barco S, Bogaard HJ, Delcroix M, Huisman MV, Konstantinides SV, Meijboom LJ, Nossent EJ, Symersky P, Vonk Noordegraaf A, Klok FA. A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension. ERJ Open Res 2021; 7:00719-2020. [PMID: 34853780 PMCID: PMC8628742 DOI: 10.1183/23120541.00719-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/14/2021] [Indexed: 11/06/2022] Open
Abstract
Background Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH)
exceeds 1 year, contributing to higher mortality. Health economic
consequences of late CTEPH diagnosis are unknown. We aimed to develop a
model for quantifying the impact of diagnosing CTEPH earlier on survival,
quality-adjusted life-years (QALYs) and healthcare costs. Material and methods A Markov model was developed to estimate lifelong outcomes, depending on the
degree of delay. Data on survival and quality of life were obtained from
published literature. Hospital costs were assessed from patient records
(n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH
referral center. Medication costs were based on a mix of standard medication
regimens. Results For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH
(median age and delay of patients in the European CTEPH Registry), lifelong
healthcare costs were estimated at EUR 117 100 for a mix of treatment
options. In a hypothetical scenario of maximal reduction of current delay,
improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs.
The associated cost increase was EUR 44 654, of which 87% was
due to prolonged medication use. This accounts for an incremental
cost–utility ratio of EUR 21 900/QALY. Conclusion Our constructed model based on the Dutch healthcare setting demonstrates a
substantial health gain when CTEPH is diagnosed earlier. According to Dutch
health economic standards, additional costs remain below the deemed
acceptable limit of EUR 50 000/QALY for the particular disease
burden. This model can be used for evaluating cost-effectiveness of
diagnostic strategies aimed at reducing the diagnostic delay. This constructed model based on the Dutch healthcare setting can be used
for evaluating cost-effectiveness of diagnostic strategies aimed at reducing
the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3
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Affiliation(s)
- Gudula J A M Boon
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Wilbert B van den Hout
- Dept of Biomedical Data Science - Medical Decision Making, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Marion Delcroix
- Dept of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany.,Dept of Cardiology, Democritus University of Thrace, Xanthi, Greece
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Petr Symersky
- Dept of Cardiac Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Center for Thrombosis and Hemostasis, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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44
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Ogo T, Shimokawahara H, Kinoshita H, Sakao S, Abe K, Matoba S, Motoki H, Takama N, Ako J, Ikeda Y, Joho S, Maki H, Saeki T, Sugano T, Tsujino I, Yoshioka K, Shiota N, Tanaka S, Yamamoto C, Tanabe N, Tatsumi K. Selexipag for the treatment of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 60:13993003.01694-2021. [PMID: 34824052 PMCID: PMC9260121 DOI: 10.1183/13993003.01694-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/04/2021] [Indexed: 11/05/2022]
Abstract
Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin-receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH.In this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary endpoint was the change in pulmonary vascular resistance (PVR) from baseline to week 20. The secondary endpoints were changes in other haemodynamic parameters, 6-min walk distance (6 WMD), Borg Dyspnoea Scale score, World Health Organisation (WHO) functional class, EuroQol 5 dimensions 5-level and N-terminal pro-brain natriuretic peptide.The change in PVR was -98.2±111.3 dyn·s·cm-5 and -4.6±163.6 dyn·s·cm-5 in the selexipag and placebo groups, respectively (mean difference, -93.5 dyn·s·cm-5; 95% confidence interval, -156.8, -30.3; p=0.006). The changes in cardiac index (p<0.001) and Borg Dyspnoea Scale score (p=0.036) were also significantly improved over placebo. 6WMD and WHO functional class were not significantly improved. The common adverse events in the selexipag group were corresponded to those generally observed following a prostacyclin analogue is administered.Selexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.
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Affiliation(s)
- Takeshi Ogo
- Division of Advanced Medical Research in Pulmonary Hypertension, Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Centre, Okayama, Okayama, Japan
| | - Hideyuki Kinoshita
- Department of Community Medicine Supporting System, Kyoto University Graduate School of Medicine, Kyoto, Kyoto, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kohtaro Abe
- Departments of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Fukuoka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Hirohiko Motoki
- Department of Cardiology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yasuhiro Ikeda
- Department of Cardiology, Yamaguchi Prefectural Grand Medical Centre, Hofu, Yamaguchi, Japan
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Hisataka Maki
- Department of Cardiology, The University of Tokyo Hospital, Tokyo, Tokyo, Japan
| | - Takahiro Saeki
- Cardiovascular Medicine, National Hospital Organization Kanazawa Medical Centre, Kanazawa, Ishikawa, Japan
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ichizo Tsujino
- Internal Medicine I, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Koichiro Yoshioka
- Department of Cardiology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Naoki Shiota
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Shinichi Tanaka
- Data Science Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Chieko Yamamoto
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan.,Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
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Wang F, Sun C, Lv X, Sun M, Si C, Zhen Y, Guo J, Sun W, Ye Z, Wen J, Liu P. Identification of a Novel Gene Correlated With Vascular Smooth Muscle Cells Proliferation and Migration in Chronic Thromboembolic Pulmonary Hypertension. Front Physiol 2021; 12:744219. [PMID: 34858201 PMCID: PMC8632225 DOI: 10.3389/fphys.2021.744219] [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: 07/22/2021] [Accepted: 10/05/2021] [Indexed: 01/29/2023] Open
Abstract
Objective: Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by thrombofibrotic obstruction of the proximal pulmonary arteries, which result in vascular remodeling of the distal pulmonary artery. While the cellular and molecular mechanisms underlying CTEPH pathogenesis remain incompletely understood, recent evidence implicates vascular remodeling. Here, we identify the molecular mechanisms that contribute to vascular remodeling in CTEPH. Methods: Microarray data (GSE130391) for patients with CTEPH and healthy controls were downloaded from the Gene Expression Omnibus (GEO) and screened for differentially expressed genes (DEGs). DEGs were functionally annotated using Gene Ontology (GO) functional analysis and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analysis. A protein-protein interaction (PPI) network was constructed to identify hub genes. Finally, pulmonary artery samples were harvested from patients with CTEPH (n = 10) and from controls (n = 10) and primary vascular smooth muscle cells (VSMCs) were cultured. Effects of the proto-oncogene FOS on VSMC proliferation and migration were assessed using expression and knockdown studies. Results: We detected a total of 292 DEGs, including 151 upregulated and 141 downregulated genes. GO analysis revealed enrichment of DEGs in biological processes of signal transduction, response to lipopolysaccharide, signal transduction, and myeloid dendritic cell differentiation. Molecular function analysis revealed enrichment in tumor necrosis factor (TNF)-activated receptor activity, transcriptional activator activity, and protein homodimerization activity. The expression of TNF-α and its receptor (sTNFR1 and sTNFR2) were significantly higher in CTEPH group, compared with control group. KEGG pathway analysis revealed enrichment in salmonella infection, pathways in cancer, osteoclast differentiation, and cytokine-cytokine receptor interaction. Hub genes in the PPI included FOS, suggesting an important role for this gene in vascular remodeling in CTEPH. Primary VSMCs derived from patients with CTEPH showed increased FOS expression and high proliferation and migration, which was attenuated by FOS inhibition. In control VSMCs, TNF-α treatment increased proliferation and migration, which FOS inhibition likewise attenuated. Conclusion: TNF-α drives CTEPH pathogenesis by promoting VSMC proliferation and migration via increased FOS expression. These results advance our understanding of the molecular mechanisms of vascular remodeling in CTEPH, and may inform the development of new therapeutic targets.
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Affiliation(s)
- Feng Wang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Congrui Sun
- Department of Cardiovascular Surgery, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaoshuo Lv
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Mingsheng Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Chaozeng Si
- Department of Operations and Information Management, China-Japan Friendship Hospital, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jing Guo
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Weiliang Sun
- Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Jianyan Wen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
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Prevalence of Micronutrient Deficiencies and Relationship with Clinical and Patient-Related Outcomes in Pulmonary Hypertension Types I and IV. Nutrients 2021; 13:nu13113923. [PMID: 34836178 PMCID: PMC8617670 DOI: 10.3390/nu13113923] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 01/24/2023] Open
Abstract
Background: Pulmonary hypertension (PH) is a rare progressive and lethal disease affecting pulmonary arteries and heart function. The disease may compromise the nutritional status of the patient, which impairs their physical performance. This study aimed to determine the prevalence of micronutrient deficiencies in pulmonary arterial hypertension (PAH) and chronic thrombo-embolic pulmonary hypertension (CTEPH) patients. Methods: Eighty-one blood samples from a prospective observational cohort study were analyzed for concentrations of micronutrients and inflammation-related factors. The samples consisted of newly diagnosed (treatment-naive) PAH and CTEPH patients and patients treated for 1.5 years according to ERS/ESC guidelines. Results: In the newly diagnosed group, 42% of PAH patients and 21% of CTEPH patients were iron deficient compared to 29% of PAH patients and 20% of CTEPH patients in the treatment group. Vitamin D deficiency occurred in 42% of the newly diagnosed PAH patients, 71% of the newly diagnosed CTEPH patients, 68% of the treated PAH patients, and 70% of the treated CTEPH patients. Iron levels correlated with the 6 min walking distance (6MWD). Conclusions: Iron and vitamin D deficiencies are highly prevalent in PAH and CTEPH patients, underlining the need for monitoring their status. Studies evaluating the effects of supplementation strategies for iron and vitamin D are necessary.
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Newman J, Boubriak I, Jenkins D, Ng C, Ruggiero A, Screaton N, Cannon J, Toshner M. Rising COVID-19 related acute pulmonary emboli but falling national chronic thromboembolic pulmonary hypertension referrals from a large national dataset. ERJ Open Res 2021; 7:00431-2021. [PMID: 34646880 PMCID: PMC8419584 DOI: 10.1183/23120541.00431-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 07/26/2021] [Indexed: 11/05/2022] Open
Abstract
The average rate of new #CTEPH referrals has dropped by 32% in the UK during the pandemic, despite the high incidence of #COVID19 related pulmonary emboli. There have been no recorded new cases of CTEPH caused by COVID-19. A prospective study is underway. https://bit.ly/37msP2G.
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Affiliation(s)
| | | | | | - Choo Ng
- Royal Papworth Hospital, Cambridge, UK
| | | | | | | | - Mark Toshner
- Royal Papworth Hospital, Cambridge, UK.,Dept of Medicine, Heart Lung Research Institute, University of Cambridge, Cambridge, UK
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48
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Cullivan S, McCormack C, O’Callaghan M, Kevane B, NiAinle F, McCullagh B, Gaine SP. Characteristics of chronic thromboembolic pulmonary hypertension in Ireland. Pulm Circ 2021; 11:20458940211048703. [PMID: 34646498 PMCID: PMC8504238 DOI: 10.1177/20458940211048703] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and under-recognised complication of acute pulmonary embolism. Information regarding the characteristics of CTEPH in Ireland is limited, and the aim of this retrospective cohort study was to address this knowledge gap. Seventy-two cases of CTEPH were diagnosed in the National Pulmonary Hypertension Unit (NPHU) in Ireland between 2010 and 2020. This accounted for 6% of all referrals to the unit and translates to an estimated annual incidence of 1.39 per million population (95% confidence interval, 0.33-2.46). The prevalence of diagnosed CTEPH in Ireland in 2020 was estimated at 12.05 per million population (95% CI 9.00-15.10). The average duration of symptoms prior to CTEPH diagnosis was 23 (±22) months. Patients with CTEPH were more likely to be male (n = 40, 56%), older (60 ± 17 years) and have identifiable risk factors for CTEPH (n = 61, 85%) at diagnosis. Regarding treatment, pulmonary hypertension (PH) vasodilator therapy was prescribed in 75% (n = 54) within 12 months of diagnosis, inferior vena cava filters were placed in 24% (n = 17) and 97% (n = 70) of cases were anticoagulated. Pulmonary endarterectomy was performed in 35% (n = 25), balloon pulmonary angioplasty in 6% (n = 4). One-, three- and five-year survival was 93%, 80% and 65% from the time of diagnosis, and this was significantly better in patients who underwent pulmonary endarterectomy (p = 0.01). This is the first study describing the characteristics of CTEPH in Ireland and highlights suboptimal disease recognition and referral for the assessment for pulmonary endarterectomy.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciara McCormack
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marissa O’Callaghan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Barry Kevane
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala NiAinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian McCullagh
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean P. Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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49
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Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center. J Clin Med 2021; 10:jcm10184251. [PMID: 34575363 PMCID: PMC8466098 DOI: 10.3390/jcm10184251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Clinical presentation, disease distribution, or treatment received may provide insights into the reasons contributing to sex differences in chronic thromboembolic pulmonary hypertension (CTEPH). (2) Methods: We evaluated 453 patients (56% women) between 2007-2019. Data was collected from REHAP (Registro Español de Hipertensión Arterial Pulmonar) registry. Two time periods were selected to evaluate the influence of new treatments over time. (3) Results: Women were older. Baseline functional class was worse, and distance walked shorter in women compared with men. Women had higher pulmonary vascular resistances. Despite this, pulmonary endarterectomy (PEA) was carried out in more men, and women received more frequently pulmonary vasodilators exclusively. The 2014-2019 interval was associated with a better survival only among women. Interestingly, women had a more distal disease during this second period of time. (4) Conclusions: Even though women were older, and received invasive treatments less frequently, mortality was similar in both sexes. The introduction of balloon pulmonary angioplasty and the improvement of pulmonary endarterectomy, especially during the last years, could be associated with a survival benefit among women.
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50
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Guth S, D'Armini AM, Delcroix M, Nakayama K, Fadel E, Hoole SP, Jenkins DP, Kiely DG, Kim NH, Lang IM, Madani MM, Matsubara H, Ogawa A, Ota-Arakaki JS, Quarck R, Sadushi-Kolici R, Simonneau G, Wiedenroth CB, Yildizeli B, Mayer E, Pepke-Zaba J. Current strategies for managing chronic thromboembolic pulmonary hypertension: results of the worldwide prospective CTEPH Registry. ERJ Open Res 2021; 7:00850-2020. [PMID: 34409094 PMCID: PMC8365143 DOI: 10.1183/23120541.00850-2020] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 06/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Pulmonary endarterectomy (PEA), pulmonary arterial hypertension (PAH) therapy and balloon pulmonary angioplasty (BPA) are currently accepted therapies for chronic thromboembolic pulmonary hypertension (CTEPH). This international CTEPH Registry identifies clinical characteristics of patients, diagnostic algorithms and treatment decisions in a global context. Methods 1010 newly diagnosed consecutive patients were included in the registry between February 2015 and September 2016. Diagnosis was confirmed by right heart catheterisation, ventilation–perfusion lung scan, computerised pulmonary angiography and/or invasive pulmonary angiography after at least 3 months on anticoagulation. Results Overall, 649 patients (64.3%) were considered for PEA, 193 (19.1%) for BPA, 20 (2.0%) for both PEA and BPA, and 148 (14.7%) for PAH therapy only. Reasons for PEA inoperability were technical inaccessibility (n=235), comorbidities (n=63) and patient refusal (n=44). In Europe and America and other countries (AAO), 72% of patients were deemed suitable for PEA, whereas in Japan, 70% of patients were offered BPA as first choice. Sex was evenly balanced, except in Japan where 75% of patients were female. A history of acute pulmonary embolism was reported for 65.6% of patients. At least one PAH therapy was initiated in 35.8% of patients (26.2% of PEA candidates, 54.5% of BPA candidates and 54.1% of those not eligible for either PEA or BPA). At the time of analysis, 39 patients (3.9%) had died of pulmonary hypertension-related causes (3.5% after PEA and 1.8% after BPA). Conclusions The registry revealed noticeable differences in patient characteristics (rates of pulmonary embolism and sex) and therapeutic approaches in Japan compared with Europe and AAO. There are distinct regional differences in the management of CTEPH patients but globally, the proportion of patients managed by PEA remains stable, independently of the new established treatment options of PAH therapies and BPAhttps://bit.ly/3zEXxkv
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Affiliation(s)
- Stefan Guth
- Dept of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | - Andrea M D'Armini
- Cardiac Surgery, Heart-Lung Transplantation and CTEPH, University of Pavia, School of Medicine, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Marion Delcroix
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Kazuhiko Nakayama
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Japan
| | - Elie Fadel
- Research and Innovation Unit, INSERM UMR-S 999, Marie Lannelongue Hospital, Univ Paris Sud, Paris-Saclay University, Le Plessis Robinson, France; Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Univ Paris Sud, Paris-Saclay University, Le Plessis Robinson, France; Paris-Sud University and Paris-Saclay University, School of Medicine, Kremlin-Bicêtre, France
| | | | | | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California San Diego, La Jolla, CA, USA
| | - Irene M Lang
- Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Michael M Madani
- Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Jaquelina S Ota-Arakaki
- Pulmonary Circulation Group and Pulmonary Function and Exercise Physiology Unit, Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo (Unifesp), São Paulo, SP, Brazil
| | - Rozenn Quarck
- Clinical Dept of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Dept of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Roela Sadushi-Kolici
- Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | | | - Bedrettin Yildizeli
- Dept of Thoracic Surgery, Marmara University School of Medicine, Istanbul, Turkey
| | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
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