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Tenes A, García-Sánchez A, Pintado-Cort B, González-Castro S, Briceño W, Durán D, Morillo R, Jiménez D. Chronic thromboembolic pulmonary hypertension treatment and sex: Systematic review and meta-analysis. Med Clin (Barc) 2024:S0025-7753(24)00275-6. [PMID: 38908993 DOI: 10.1016/j.medcli.2024.03.014] [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: 01/29/2024] [Revised: 03/06/2024] [Accepted: 03/11/2024] [Indexed: 06/24/2024]
Abstract
BACKGROUND AND OBJECTIVES Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and a major cause of chronic pulmonary hypertension leading to right heart failure and death. While pulmonary endarterectomy is the treatment of choice, some patients might benefit from medical therapy or balloon pulmonary angioplasty. Sex differences in outcomes of these therapies are not well characterized. MATERIAL AND METHODS We conducted a systematic review and meta-analysis to investigate sex differences in outcomes of various therapies for CTEPH. We searched MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library databases between January 1, 2010 and April 30, 2021, published in English. We pooled incidence estimates using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic. We assessed publication bias using Begg's and Egger's tests. This study is registered in PROSPERO, CRD42021268504. RESULTS A total of 19 studies met the eligibility criteria, but only 3 trials provided separate outcomes for women and men. Two studies evaluated the efficacy of BPA, and one study evaluated the efficacy of riociguat (129 patients). Overall, 57.3% of patients were women and 62.6% were in functional class III. Mean time of follow-up was 55.5 (SD 26.1) weeks. Women showed a significantly better response in cardiac index (mean difference [MD], 0.10L/min/m2; 95% confidence interval [CI], 0.04-0.16; I2=0%; P=0.001). Alternatively, the reduction of pulmonary vascular resistances was significantly higher for men than for women (MD, 161.17dynscm-5; 95% CI, 67.99-254.35; I2=0%; P=0.0007). CONCLUSIONS Women and men might show different hemodynamic responses to riociguat or BPA for CTEPH.
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Affiliation(s)
- Andrés Tenes
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain.
| | - Aldara García-Sánchez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Beatriz Pintado-Cort
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Sara González-Castro
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Winnifer Briceño
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Diego Durán
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria IRYCIS, Madrid, Spain; CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain; Medicine Department, Universidad de Alcalá, Madrid, Spain
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Páez-Carpio A, Vollmer I, Zarco FX, Matute-González M, Domenech-Ximenos B, Serrano E, Barberà JA, Blanco I, Gómez FM. Imaging of chronic thromboembolic pulmonary hypertension before, during and after balloon pulmonary angioplasty. Diagn Interv Imaging 2024; 105:215-226. [PMID: 38413273 DOI: 10.1016/j.diii.2024.02.005] [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: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
Balloon pulmonary angioplasty (BPA) has recently been elevated as a class I recommendation for the treatment of inoperable or residual chronic thromboembolic pulmonary hypertension (CTEPH). Proper patient selection, procedural safety, and post-procedural evaluation are crucial in the management of these patients, with imaging work-up playing a pivotal role. Understanding the diagnostic and therapeutic imaging algorithms of CTEPH, the imaging features of patients amenable to BPA, all imaging findings observed during and immediately after the procedure and the changes observed during the follow-up is crucial for all interventional radiologists involved in the care of patients with CTEPH. This article illustrates the imaging work-up of patients with CTEPH amenable to BPA, the imaging findings observed before, during and after BPA, and provides a detailed description of all imaging modalities available for CTEPH evaluation.
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Affiliation(s)
- Alfredo Páez-Carpio
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Department of Medical Imaging, University of Toronto, Toronto M5T 1W7, ON, Canada; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain.
| | - Ivan Vollmer
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | - Federico X Zarco
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | | | | | - Elena Serrano
- Department of Radiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat 08907, Spain
| | - Joan A Barberà
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Isabel Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Fernando M Gómez
- Interventional Radiology Unit, Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain; Interventional Radiology Unit, Department of Radiology, The Netherlands Cancer Institute, Amsterdam 1066 CX, the Netherlands
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Carlozzi LN, Lin CH, Steinberg ZL. Balloon Pulmonary Angioplasty for the Treatment of Chronic Thromboembolic Pulmonary Hypertension. Methodist Debakey Cardiovasc J 2024; 20:57-64. [PMID: 38765209 PMCID: PMC11100548 DOI: 10.14797/mdcvj.1347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/23/2024] [Indexed: 05/21/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension in patients who have evidence of chronic thromboembolic occlusion of the pulmonary vasculature. Historically, surgical pulmonary thromboendarterectomy has been the treatment of choice. However, with up to 40% of patients deemed inoperable, balloon pulmonary angioplasty has emerged as an additional treatment strategy. Balloon pulmonary angioplasty is a complementary strategy alongside surgical pulmonary thromboendarterectomy and offers the opportunity for pulmonary revascularization in patients who have more distal disease, higher comorbidities, or residual obstruction following operative intervention. This review examines the history of balloon pulmonary angioplasty, highlights its effectiveness, discusses important complications and risk reduction strategies, and emphasizes the importance of centers forming a multidisciplinary team of providers to manage the complexity of patients with chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
| | - C. Huie Lin
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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Kanezawa M, Shimokawahara H, Ejiri K, Goten C, Okada H, Sato K, Yuasa S, Matsubara H. Effects of medical therapy and age on cardiac output changes following balloon pulmonary angioplasty: Implications for combination therapy in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2024:S1053-2498(24)01661-9. [PMID: 38759765 DOI: 10.1016/j.healun.2024.05.007] [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: 02/06/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Some patients with chronic thromboembolic pulmonary hypertension (CTEPH) exhibit exercise intolerance due to reduced cardiac output (CO) even after successful balloon pulmonary angioplasty (BPA). Medical therapy is a potential option for such cases; however, it is unclear which patients necessitate it even after BPA. METHODS This study included 286 patients with CTEPH who underwent BPA and right heart catheterization 1 year after the final BPA and classified them into no-medication and withdrawal groups. The no-medication group comprised patients without pulmonary hypertension (PH) medications before and after BPA, while the withdrawal group included patients who received PH medications before BPA and discontinued them after BPA. We assessed differences in the changes in CO after BPA from baseline (ΔCO) between the 2 groups. Additionally, we evaluated the ΔCO among different age categories within each group: younger (<60 years), middle-aged (60-70 years), and older adults (≥70 years). RESULTS After adjusting baseline covariates, overall CO did not differ significantly. However, ΔCO was significantly positive in the no-medication group but negative in the withdrawal group (0.32 and -0.33, difference in ΔCO: -0.65, 95% confidence intervals: -0.90 to -0.40). A significantly positive effect on ΔCO was observed in younger and middle-aged individuals, with a significant interaction between age and ΔCO in no-medication groups. CONCLUSIONS Increasing CO with BPA alone may be challenging with age in patients with CTEPH. Given that discontinuation of PH medication after BPA decreased CO more than the effect of BPA, medical therapy might be necessary even after successful BPA.
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Affiliation(s)
- Misaki Kanezawa
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan; Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | | | - Kentaro Ejiri
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Chiaki Goten
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Hirofumi Okada
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Kimi Sato
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
| | - Shinsuke Yuasa
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, NHO Okayama Medical Center, Okayama, Japan
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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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6
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Aggarwal V, Giri J, Visovatti SH, Mahmud E, Matsubara H, Madani M, Rogers F, Gopalan D, Rosenfield K, McLaughlin VV. Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1090-e1107. [PMID: 38450477 DOI: 10.1161/cir.0000000000001197] [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] [Indexed: 03/08/2024]
Abstract
Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.
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7
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Wang Y, Guo D, Gong J, Wang J, Yang Y, Zhang X, Hu H, Ma Y, Lv X, Li Y. Efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with pulmonary comorbidity. IJC HEART & VASCULATURE 2024; 51:101363. [PMID: 38445233 PMCID: PMC10912838 DOI: 10.1016/j.ijcha.2024.101363] [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: 12/04/2023] [Revised: 01/26/2024] [Accepted: 02/11/2024] [Indexed: 03/07/2024]
Abstract
Background Balloon pulmonary angioplasty (BPA) is an established treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but its efficacy in CTEPH patients with a pulmonary comorbidity has not been well-studied. Here, we compared post-BPA outcomes between CTEPH patients with and without chronic pulmonary disease at baseline and analyzed predictors of BPA success. Methods From August 2017 to October 2022, 62 patients with inoperable CTEPH who underwent BPA were consecutively enrolled and grouped based on the presence of a pulmonary comorbidity at baseline. All patients underwent transthoracic echocardiography, pulmonary function tests, and right heart catheterization. Pre- and post-BPA data were evaluated to identify factors that influence the success of BPA. Results Among the 62 CTEPH patients, BPA was considered successful in 50 patients and unsuccessful in 12 patients. Responders to BPA had better exercise capacity and right heart function at baseline, but no differences in hemodynamic or respiratory function were detected between the groups. In CTEPH patients with chronic pulmonary disease (n = 14), BPA significantly improved mean pulmonary arterial pressure, pulmonary vascular resistance and right heart function parameters. Only CTEPH patients without chronic pulmonary disease (n = 48) exhibited significant improvement in 6-minute walk distance and respiratory function. Multivariate logistic regression analysis showed that pulmonary comorbidity at baseline was independently associated with the efficacy of BPA. Conclusions BPA provided significantly improvements in hemodynamics and right heart function in CTEPH patients, independent of pulmonary comorbidity at baseline. However, pulmonary comorbidity can negatively impact post-BPA outcomes.
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Affiliation(s)
- Yeqing Wang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Dichen Guo
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Juanni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jianfeng Wang
- Department of Intervention, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xinyuan Zhang
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huimin Hu
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yaning Ma
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xiuzhang Lv
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yidan Li
- Department of Echocardiography, Heart Center, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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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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Prins KW, Durbin J, Archer SL. Complete Revascularization of the Pulmonary Circulation in Chronic Thromboembolic Pulmonary Hypertension: Value of Addressing Chronic Total Occlusions. Can J Cardiol 2024; 40:634-636. [PMID: 38030122 PMCID: PMC11009058 DOI: 10.1016/j.cjca.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 11/23/2023] [Accepted: 11/24/2023] [Indexed: 12/01/2023] Open
Affiliation(s)
- Kurt W Prins
- Cardiovascular Division, Lillehei Heart Institute, University of Minnesota, Minneapolis, Minnesota, USA
| | - Josh Durbin
- Department of Medicine (Cardiology), Queen's University, Kingston, Ontario, Canada
| | - Stephen L Archer
- Department of Medicine (Cardiology), Queen's University, Kingston, Ontario, Canada; Translational Institute of Medicine, Department of Medicine, Queen's University, Kingston, Ontario, Canada.
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Caspersen CK, Ingemann-Molden S, Grove EL, Højen AA, Andreasen J, Klok FA, Rolving N. Performance-based outcome measures for assessing physical capacity in patients with pulmonary embolism: A scoping review. Thromb Res 2024; 235:52-67. [PMID: 38301376 DOI: 10.1016/j.thromres.2024.01.008] [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: 08/23/2023] [Revised: 12/22/2023] [Accepted: 01/10/2024] [Indexed: 02/03/2024]
Abstract
INTRODUCTION Up to 50 % of patients surviving a pulmonary embolism (PE) report persisting shortness of breath, reduced physical capacity and psychological distress. As the PE population is heterogeneous compared to other cardiovascular patient groups, outcome measures for assessing physical capacity traditionally used in cardiac populations may not be reliable for the PE population as a whole. This scoping review aims to 1) map performance-based outcome measures (PBOMs) used for assessing physical capacity in PE research, and 2) to report the psychometric properties of the identified PBOMs in a PE population. METHODS The review was conducted according to the Joanna Briggs Institute framework for scoping reviews and reported according to the PRISMA-Extension for Scoping Reviews guideline. RESULTS The systematic search of five databases identified 4585 studies, of which 243 studies met the inclusion criteria. Of these, 185 studies focused on a subgroup of patients with chronic thromboembolic pulmonary hypertension. Ten different PBOMs were identified in the included studies. The 6-minute walk test (6MWT) and cardiopulmonary exercise test (CPET) were the most commonly used, followed by the (Modified) Bruce protocol and Incremental Shuttle Walk test. No studies reported psychometric properties of any of the identified PBOMs in a PE population. CONCLUSIONS Publication of studies measuring physical capacity within PE populations has increased significantly over the past 5-10 years. Still, not one study was identified, reporting the validity, reliability, or responsiveness for any of the identified PBOMs in a PE population. This should be a priority for future research in the field.
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Affiliation(s)
| | - Stian Ingemann-Molden
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Anette Arbjerg Højen
- Department of Health Science and Technology, Aalborg University, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Jane Andreasen
- Department of Physiotherapy and Occupational Therapy, Aalborg University Hospital, Denmark; Department of Health Science and Technology, Aalborg University, Denmark; Aalborg Health and Rehabilitation Centre, Aalborg Municipality, Denmark
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, the Netherlands
| | - Nanna Rolving
- Department of Physiotherapy and Occupational Therapy, Aarhus University Hospital, Denmark; Department of Public Health, Aarhus University, Denmark.
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Łabyk A, Krakowian M, Mysiorski Ł, Lichodziejewska B, Dzikowska-Diduch O, Ou-Pokrzewińska A, Zieliński D, Gołębiowski M, Pruszczyk P, Roik M. Refined balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension - reference center experience. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2024; 20:84-88. [PMID: 38616936 PMCID: PMC11008523 DOI: 10.5114/aic.2024.136411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Chronic thromboembolic pulmonary hypertension (CTEPH), characterized by thromboembolic changes affecting the pulmonary bed, leads to ventricular function deterioration and premature death. The introduction of balloon pulmonary angioplasty (BPA) has significantly improved the prognosis of CTEPH patients. Aim The authors of this article decided to summarize the experience of the BPA program, conducted between 2014 and 2022, at the reference center. Material and methods Among 111 CTEPH patients, 55 were included in the analysis. A total of 226 sessions were performed, with a significant percentage of intravascular imaging and pressure catheter use. Results Mean pulmonary pressure decreased significantly from 42 (22-66) to 26.5 mm Hg (11-54) (p < 0.05). Pulmonary vascular resistance and natriuretic peptide concentration decreased from 6.67 (1.66-14) to 3.295 Wood units (1.09-11.11), respectively, and from 1934 (60-16963) to 296 (21-9901) ng/ml (p < 0.05). There was also an improvement in the functional class (WHO) from 2.85 ±0.61 to 2.15 ±0.62 and an increase in the 6-minute walking distance from 300 ±131 to 367 ±154 m (p < 0.05). There were no in-hospital deaths or within 30 days of the procedure. Arterial damage occurred during nine sessions (n = 9/226, 4%), while 0.9% (n = 2/226) were complicated by acute right ventricular failure. Post-reperfusion pulmonary edema (RPE 0 - none) was observed in almost 90% of the sessions, grade 1 to 3 RPE occurred in 10.2%, and grade 4 RPE was not noted. Conclusions BPA programs conducted in experienced centers are a safe and effective treatment option for inoperable CTEPH patients.
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Affiliation(s)
- Andrzej Łabyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Krakowian
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Łukasz Mysiorski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Olga Dzikowska-Diduch
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Aisha Ou-Pokrzewińska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | | | - Marek Gołębiowski
- 1 Department of Radiology, Medical University of Warsaw, Infant Jesus Teaching Hospital Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
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Piliero N, Salvat M, Finas M, Curioz F, Traclet J, Ahmad K, Bertoletti L, Vautrin E, Bouvaist H, Degano B. Upfront triple therapy with parenteral prostanoid as a bridge to balloon pulmonary angioplasty in severe chronic thromboembolic pulmonary hypertension. ERJ Open Res 2024; 10:00085-2024. [PMID: 38444667 PMCID: PMC10910263 DOI: 10.1183/23120541.00085-2024] [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: 12/08/2023] [Accepted: 01/25/2024] [Indexed: 03/07/2024] Open
Abstract
In patients with very severe CTEPH eligible for BPA, it is possible to achieve major haemodynamic improvement with upfront triple PH therapy including epoprostenol and then to perform angioplasties https://bit.ly/3vZZvib.
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Affiliation(s)
- Nicolas Piliero
- Service de Cardiologie, CHU Grenoble Alpes, Grenoble, France
| | - Muriel Salvat
- Service de Cardiologie, CHU Grenoble Alpes, Grenoble, France
| | - Mathieu Finas
- Service de Radiologie, CHU Grenoble Alpes, Grenoble, France
| | - Florence Curioz
- Service de Cardiologie, CHU Grenoble Alpes, Grenoble, France
| | - Julie Traclet
- Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares, Hôpital Louis-Pradel, Université de Lyon, Lyon, France
| | - Kaïs Ahmad
- Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares, Hôpital Louis-Pradel, Université de Lyon, Lyon, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de St-Etienne, Saint-Etienne, France
- INSERM, UMR1059, Équipe Dysfonction Vasculaire et Hémostase, Université Jean-Monnet, Saint-Etienne, France
- INSERM, CIC-1408, CHU Saint-Etienne, Saint-Etienne, France
| | - Estelle Vautrin
- Service de Cardiologie, CHU Grenoble Alpes, Grenoble, France
| | - Hélène Bouvaist
- Service de Cardiologie, CHU Grenoble Alpes, Grenoble, France
| | - Bruno Degano
- INSERM U1300, Laboratoire HP2, Université Grenoble Alpes, Grenoble, France
- Service de Pneumologie, CHU Grenoble Alpes, Grenoble, France
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13
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Ribas Sola J, Sánchez-Corral Mena MÁ, Riera-Mestre A. [Update in the management of chronic thrombo-embolic pulmonary hypertension]. Med Clin (Barc) 2024; 162:126-133. [PMID: 37925273 DOI: 10.1016/j.medcli.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/06/2023]
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.
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Affiliation(s)
- Jesús Ribas Sola
- Unidad de Enfermedades Vasculares Pulmonares, Servicio de Neumología, Hospital Universitari de Bellvitge, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España.
| | - Miguel Ángel Sánchez-Corral Mena
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España; Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España
| | - Antoni Riera-Mestre
- Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España; Unidad Funcional de ETV, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España.
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14
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Crowley AV, Banfield M, Gupta A, Raj R, Gorantla VR. Role of Surgical and Medical Management of Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review. Cureus 2024; 16:e53336. [PMID: 38435894 PMCID: PMC10907114 DOI: 10.7759/cureus.53336] [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] [Accepted: 01/31/2024] [Indexed: 03/05/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is underdiagnosed and has recently surfaced as one of the leading triggers of severe pulmonary hypertension. This disease process is described by structural changes of pulmonary arteries such as fibrous stenosis, complete obliteration, or the presence of a resistant intraluminal thrombus, resulting in increased pulmonary resistance and eventually progressing to right-sided heart failure. Hence, this study aims to describe the current treatments for CTEPH and their efficacy in hemodynamic improvement and prevention of recurring thromboembolic episodes in patients. This systematic review promptly follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. On February 13, 2022, our team searched through the following databases: PubMed, ProQuest, and ScienceDirect. The following keywords were used across all databases: CTEPH AND Pulmonary Endarterectomy (PEA), CTEPH AND Balloon Pulmonary Angioplasty (BPA), and CTEPH AND Medical Therapy OR Anticoagulation therapy. Twenty-nine thousand eighty-nine articles on current management techniques (PEA, Balloon angioplasty, anticoagulants) were selected, analyzed, and reviewed with each other. We found 19 articles concerning PEA, 15 concerning BPA, and six regarding anticoagulants. Most papers showed high success rates and promising evidence of PEA and anticoagulants as a post-operative regimen. BPA was the least preferred but is still reputable in patients unfit for invasive techniques. CTEPH is a condition presenting with either fibrous stenosis, complete obliteration of the artery, or a clogged thrombus. Recent studies have shown three techniques that physicians have used to treat CTEPH: balloon-pulmonary angioplasty, PEA, and medical management with anticoagulants. PEA followed by anticoagulants is preferred to balloon pulmonary angioplasties. CTEPH is an ongoing topic in research; as it continues to be researched, we hope to see more management techniques available.
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Affiliation(s)
- Alexandra V Crowley
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Megan Banfield
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Aditi Gupta
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Rhea Raj
- Medicine, St. George's University School of Medicine, True Blue, St. George's, GRD
| | - Vasavi R Gorantla
- Biomedical Sciences, West Virginia School of Osteopathic Medicine, Lewisburg, USA
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15
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Verbelen T, Godinas L, Dorfmüller P, Gopalan D, Condliffe R, Delcroix M. Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2023; 32:230149. [PMID: 38123236 PMCID: PMC10731457 DOI: 10.1183/16000617.0149-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
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16
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Xin L, Zhang Y, Luo Q, Zhao Q, Yang T, Zeng Q, Jin Q, Duan A, Huang Z, Hu M, Zhang S, Gao L, Xiong C, Zhao Z, Liu Z. Development and validation of a nomogram for predicting hemodynamic response to balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. Respir Med 2023; 220:107440. [PMID: 37940060 DOI: 10.1016/j.rmed.2023.107440] [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: 06/30/2023] [Revised: 10/12/2023] [Accepted: 10/22/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) can effectively alleviate pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Identifying predictors of unfavorable hemodynamic response to BPA is essential to guide clinical practice. Therefore, our objective was to construct and validate a nomogram to facilitate clinicians predicting hemodynamic response to BPA. METHODS Patients with CTEPH and underwent BPA from May 2018 to April 2022 were retrospectively collected. Favorable hemodynamic response to BPA was defined as a mean pulmonary arterial pressure ≤30 mmHg and/or a reduction in pulmonary vascular resistance ≥30 % at follow-up. RESULTS A total of 155 patients were included. At baseline, patients with favorable hemodynamic response had significantly lower proportion of occlusive lesions (11.11 % vs. 26.32 %, P = 0.017), higher diffusing capacity of the lungs for carbon monoxide (63.77 % ± 14.10 % vs. 59.11 % ± 11.78 %, P = 0.039), and better cardiac morphology than counterparts. LASSO regression and random forest were used to construct prediction models respectively. The LASSO regression model demonstrated better predictive ability and accuracy than the random forest model, as evidenced by higher area under curve (0.745 vs. 0.740) and lower Brier score (0.192 vs. 0.195). A nomogram was constructed based on the LASSO regression model, consisting of right ventricular end-diastolic diameter/left ventricular end-diastolic diameter, number of treated pulmonary vessels and proportion of occlusion lesions. High predictive ability of the LASSO model was preserved in validation (C index 0.744). CONCLUSIONS The current study constructed a nomogram with high accuracy in predicting BPA hemodynamic outcome, which could facilitate decision-making in clinical practice.
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Affiliation(s)
- Li Xin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of ICU, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qing Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Tao Yang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qixian Zeng
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Anqi Duan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihua Huang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Meixi Hu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Sicheng Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Luyang Gao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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17
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Ito R, Yamashita J, Ikeda S, Nakajima Y, Kasahara T, Sasaki Y, Suzuki S, Takahashi L, Komatsu I, Murata N, Shimahara Y, Ogino H, Chikamori T. Predictors of procedural complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. J Cardiol 2023; 82:497-503. [PMID: 37380068 DOI: 10.1016/j.jjcc.2023.06.011] [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: 02/07/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is an effective treatment for inoperable chronic thromboembolic pulmonary hypertension, with good results reported for residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). However, BPA is associated with complications, such as pulmonary artery perforation and vascular injury, which can lead to critical pulmonary hemorrhage requiring embolization and mechanical ventilation. Furthermore, the risk factors for occurrence of complications in BPA are unclear; therefore, this study aimed to evaluate predictors of procedural complications in BPA. METHODS In this retrospective study, we collected clinical data (patient characteristics, details of medical therapy, hemodynamic parameters, and details of the BPA procedure) from 321 consecutive sessions involving 81 patients who underwent BPA. Procedural complications were evaluated as endpoints. RESULTS BPA for residual PH after PEA was performed in 141 sessions (43.9 %), which involved 37 patients. Procedural complications were observed in 79 sessions (24.6 %), including severe pulmonary hemorrhage requiring embolization in 29 sessions (9.0 % of all sessions). No patients experienced severe complications requiring intubation with mechanical ventilation or extracorporeal membrane oxygenation. Age ≥ 75 years and mean pulmonary artery pressure ≥ 30 mmHg were independent predictors of procedural complications. Residual PH after PEA was a significant predictor of severe pulmonary hemorrhage requiring embolization (adjusted odds ratio, 3.048; 95 % confidence interval, 1.042-8.914, p = 0.042). CONCLUSIONS Older age, high pulmonary artery pressure, and residual PH after PEA increase the risk of severe pulmonary hemorrhage requiring embolization in BPA.
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Affiliation(s)
- Ryosuke Ito
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Sayo Ikeda
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yuki Nakajima
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Tomohiro Kasahara
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yuichi Sasaki
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Shun Suzuki
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Lisa Takahashi
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Ikki Komatsu
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Naotaka Murata
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yusuke Shimahara
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Taishiro Chikamori
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
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18
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Delcroix M, Belge C, Maleux G, Godinas L. Monographic Issue on Pulmonary Hypertension: Medical and Interventional Treatment for Chronic Thromboembolic Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:840-850. [PMID: 37567250 DOI: 10.1055/s-0043-1770122] [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: 08/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. The reasons why clots do not resorb are incompletely understood, but the result is partial or complete fibrothrombotic obstruction of pulmonary arteries. A secondary microvasculopathy aggravates the pulmonary hypertension (PH) as a consequence of high flow and shear stress in the nonoccluded arteries. The treatment of CTEPH has long been purely surgical, but many patients were inoperable because of inaccessible lesions or severe comorbidities. Alternatives were developed, including medical therapy and more recently balloon pulmonary angioplasty (BPA). Depending on the generation of the obstructed vessels, the treatment will be surgical, up to the (sub)segmental level, or by BPA for more distal vessels. PH drugs are used to treat the microvasculopathy. The current paper describes the therapeutic management of inoperable patients: the medical approach with PH drugs used in mono- or combination therapy; the proper use of anticoagulants in CTEPH; the technique, indications, and results at short- and long-term of BPA; the multimodal approach for inoperable patients combining PH drugs and BPA; and the effects of rehabilitation. It shows the importance of a multidisciplinary approach to the disease.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
| | - Catharina Belge
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
| | - Geert Maleux
- Clinical Department of Radiology, University Hospitals of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
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19
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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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20
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Dardi F, Rotunno M, Guarino D, Suarez SM, Niro F, Loforte A, Taglieri N, Ballerini A, Magnani I, Bertozzi R, Donato F, Martini G, Manes A, Saia F, Pacini D, Galiè N, Palazzini M. Comparison of different treatment strategies in patients with chronic thromboembolic pulmonary hypertension: a single centre real-world experience. Int J Cardiol 2023; 391:131333. [PMID: 37673403 DOI: 10.1016/j.ijcard.2023.131333] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 08/18/2023] [Accepted: 09/01/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, there is a substantial proportion of patients deemed not operable in whom other treatment strategies are available: medical therapy and balloon pulmonary angioplasty (BPA). We aimed to compare different CTEPH treatment strategies effect in a real-world setting. METHODS All patients with CTEPH referred to our centre were included. We compare the short-term clinical, functional, exercise and haemodynamic effect of medical therapy (irrespective of subsequent treatment strategies), PEA and BPA (irrespective of previous/subsequent treatment strategies); we also describe the long-term outcome of the different patient groups. RESULTS We included 467 patients (39% were treated only with medical therapy, 43% underwent PEA, 13% underwent BPA and 5% were not treated with any therapy). Patients treated only with medical therapy were the oldest; compared to patients undergoing PEA, they had a lower exercise capacity, a higher risk profile and gained a lower haemodynamic, functional and survival benefit from the treatment. Patients undergoing BPA had a lower haemodynamic improvement but a comparable functional, exercise and risk improvement and a similar survival compared to patients undergoing PEA; their survival is anyway better than patients undergoing only medical treatment. Untreated historical control patients had the worst survival. CONCLUSIONS We confirm the superiority of PEA compared to any alternative treatment in CTEPH patients and we observe that BPA, in patients deemed not operable or with persistent/recurrent PH after PEA, leads to a better outcome than medical therapy alone.
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Affiliation(s)
- Fabio Dardi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy.
| | - Mariangela Rotunno
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Daniele Guarino
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Sofia Martin Suarez
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Fabio Niro
- Radiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Antonio Loforte
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Nevio Taglieri
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Alberto Ballerini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Ilenia Magnani
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Riccardo Bertozzi
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Federico Donato
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Giulia Martini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Davide Pacini
- Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy; Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Dipartimento DIMEC (Dipartimento di scienze mediche e chirurgiche), Università di Bologna, Italy
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21
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Nakazato K, Sugimoto K, Oikawa M, Takeishi Y. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension:its history and development, and regional medical cooperation in Fukushima. Fukushima J Med Sci 2023; 69:167-176. [PMID: 37766558 PMCID: PMC10694517 DOI: 10.5387/fms.2023-09] [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: 03/22/2023] [Accepted: 08/07/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is designated as an intractable disease by the Ministry of Health, Labour and Welfare of Japan, and has an extremely poor prognosis if untreated. Surgical pulmonary endarterectomy is the curative treatment for cases in which the organized thrombi are located in the central part of the pulmonary artery, but there had been no effective treatment for cases in which the thrombi are located in the peripheral part of the pulmonary artery. Recently, balloon pulmonary angioplasty (BPA), a transcatheter procedure to dilate stenotic or occluded lesions in the peripheral pulmonary artery, has been rapidly developed. Although BPA was once a globally abandoned procedure due to hemorrhagic complications, Japanese experts have improved the technique, and its safety and efficacy have been enhanced. As a result, BPA is now being reevaluated worldwide. This review describes the history and development of BPA in the treatment of CTEPH, as well as the status of this treatment in Fukushima Prefecture.
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Affiliation(s)
- Kazuhiko Nakazato
- Regional Medical Support Center, Fukushima Medical University
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University
- Futaba Emergency and General Medicine Support Center, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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22
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Provost M, Mornex JF, Nasser M, Zeghmar S, Traclet J, Ahmad K, Lestelle F, Chour A, Diesler R, Cottin V, Turquier S. Changes in the management of chronic thromboembolic pulmonary hypertension over a 10-year period, in a French expert regional competence centre. Respir Med Res 2023; 84:101021. [PMID: 37276770 DOI: 10.1016/j.resmer.2023.101021] [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: 08/24/2022] [Revised: 04/06/2023] [Accepted: 04/15/2023] [Indexed: 06/07/2023]
Abstract
Over the last few years, the advent of balloon pulmonary angioplasty (BPA) had led to changes in the management of chronic thromboembolic pulmonary hypertension (CTEPH). We reviewed data from 98 CTEPH patients diagnosed during the last decade in a pulmonary hypertension (PH) expert centre. The management modalities of 2 periods (Period A: 2011-15 and Period B: 2016-20) were compared. Age (period A: 72 [58-80] years; period B: 69 [62-79] years), clinical (New York Heart Association (NYHA) functional class III-IV: 25/41, 61% vs 39/57, 68%), and hemodynamic assessments (pulmonary vascular resistance: 7.5 [6.2-8.7] WU vs 8.0 [6.0-10.2] WU) at baseline were not significantly different. Pulmonary endarterectomy was performed in less than one third of patients (12, 29.3% vs 15, 26.3%). For patients not eligible for surgery, medical therapy was mostly prescribed alone during period A (medical therapy alone, patients diagnosed in period A: 61% vs in period B: 17.5%) while it was associated with BPA during period B (medical therapy + BPA, 12% vs 61.4%). The 5-year survival rate was excellent for patients who underwent surgery (96.3%) or BPA (95.2%), but was only 42.1% for patients under oral medication only (p < 0.0001). Patients diagnosed with CTEPH who cannot be operated should undergo BPA. The survival rate after BPA is as good as after surgery and significantly better than that of oral medication only.
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Affiliation(s)
- Mathilde Provost
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Jean-François Mornex
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 , Lyon, France
| | - Mouhamad Nasser
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Sabrina Zeghmar
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Julie Traclet
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Kais Ahmad
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - François Lestelle
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Ali Chour
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Rémi Diesler
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France
| | - Vincent Cottin
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Centre de référence coordonnateur des maladies pulmonaires rares (RespiFil), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France; Université de Lyon, université Lyon 1, INRAE, EPHE, UMR754, IVPC, F-69007 , Lyon, France
| | - Ségolène Turquier
- Centre de compétences de l'hypertension pulmonaire (Pulmo Tension), service de pneumologie, Hospices Civils de Lyon, Hôpital Louis Pradel, Lyon, France.
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23
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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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24
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Luijten D, de Jong CMM, Ninaber MK, Spruit MA, Huisman MV, Klok FA. Post-Pulmonary Embolism Syndrome and Functional Outcomes after Acute Pulmonary Embolism. Semin Thromb Hemost 2023; 49:848-860. [PMID: 35820428 DOI: 10.1055/s-0042-1749659] [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: 10/17/2022]
Abstract
Survivors of acute pulmonary embolism (PE) are at risk of developing persistent, sometimes disabling symptoms of dyspnea and/or functional limitations despite adequate anticoagulant treatment, fulfilling the criteria of the post-PE syndrome (PPES). PPES includes chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic pulmonary disease, post-PE cardiac impairment (characterized as persistent right ventricle impairment after PE), and post-PE functional impairment. To improve the overall health outcomes of patients with acute PE, adequate measures to diagnose PPES and strategies to prevent and treat PPES are essential. Patient-reported outcome measures are very helpful to identify patients with persistent symptoms and functional impairment. The primary concern is to identify and adequately treat patients with CTEPH as early as possible. After CTEPH is ruled out, additional diagnostic tests including cardiopulmonary exercise tests, echocardiography, and imaging of the pulmonary vasculature may be helpful to rule out non-PE-related comorbidities and confirm the ultimate diagnosis. Most PPES patients will show signs of physical deconditioning as main explanation for their clinical presentation. Therefore, cardiopulmonary rehabilitation provides a good potential treatment option for this patient category, which warrants testing in adequately designed and executed randomized trials. In this review, we describe the definition and characteristics of PPES and its diagnosis and management.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Cindy M M de Jong
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martijn A Spruit
- Department of Research & Development, Ciro, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre, NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Menno V Huisman
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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25
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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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26
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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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27
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Taskar V. Chronic thromboembolic pulmonary hypertension - Time is of the essence. J Postgrad Med 2023; 69:187-189. [PMID: 37843151 PMCID: PMC10846817 DOI: 10.4103/jpgm.jpgm_707_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/27/2023] [Accepted: 09/27/2023] [Indexed: 10/17/2023] Open
Affiliation(s)
- V Taskar
- Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Wellstar – MCG Health, Augusta, USA
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28
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Allwood BW, Joubert L, Janson J. Chronic thromboembolic pulmonary hypertension: More options, more awareness. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i3.1496. [PMID: 37970577 PMCID: PMC10642392 DOI: 10.7196/ajtccm.2023.v29i3.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Affiliation(s)
- B W Allwood
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health
Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - L Joubert
- Division of Cardiology, Department of Medicine, Faculty of Medicine and
Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town,
South Africa
| | - J Janson
- Division of Cardiothoracic Surgery, Department of Surgical Sciences, Faculty of
Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
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29
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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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30
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Magod BL, Quinn C, Malaisrie SC, Cuttica MJ, Schimmel D. "Refined Balloon Pulmonary Angioplasty" May Need to Be Refined. JACC. ADVANCES 2023; 2:100550. [PMID: 38939479 PMCID: PMC11198216 DOI: 10.1016/j.jacadv.2023.100550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
- Benjamin L. Magod
- Northwestern University Feinberg School of Medicine, 420 E Superior Street, Chicago, Illinois 60611, USA
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31
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Honore PM, Bousbiat I, Perriens E, Blackman S, Vornicu O, Michaux I, Dincq AS, Evrard P, Bulpa P. Chronic thromboembolic pulmonary hypertension: early recognition leads to optimal therapy and drastically decreases mortality! ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:340. [PMID: 37675319 PMCID: PMC10477628 DOI: 10.21037/atm-23-1288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/30/2023] [Indexed: 09/08/2023]
Affiliation(s)
- Patrick M. Honore
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Ibrahim Bousbiat
- ULB University Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Emily Perriens
- ULB University Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Sydney Blackman
- ULB University Centre Hospitalier Universitaire Brugmann, Brussels, Belgium
| | - Ovidiu Vornicu
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
- ICU and Anesthesiology Depts., CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Isabelle Michaux
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Anne-Sophie Dincq
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
- ICU and Anesthesiology Depts., CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Patrick Evrard
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
| | - Pierre Bulpa
- ICU, CHU UCL Godinne Namur, UCL Louvain Medical School, Yvoir, Belgium
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32
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Wiedenroth CB, Steinhaus K, Rolf A, Breithecker A, Adameit MSD, Kriechbaum SD, Haas M, Roller F, Hamm CW, Ghofrani HA, Mayer E, Guth S, Liebetrau C. Patient-Reported Long-Term Outcome of Balloon Pulmonary Angioplasty for Inoperable CTEPH. Thorac Cardiovasc Surg 2023. [PMID: 37643729 DOI: 10.1055/s-0043-1772770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is a promising interventional treatment for inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Evidence in favor of BPA is growing, but long-term data remain scarce. The Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) is validated for the assessment of patients with pulmonary hypertension within three domains: symptoms, activity, and quality of life (QoL). The aim of the present study was to evaluate the long-term effects of BPA on these domains in patients with inoperable CTEPH. METHODS Between March 2014 and August 2019, technically inoperable patients with target lesions for BPA were included in this prospective, observational study. CAMPHOR scores were compared between baseline (before the first BPA) and 6 months after the last intervention and also for scores assessed at annual follow-ups. RESULTS A total of 152 patients had completed a full series of BPA interventions and a 28 (interquartile range [IQR]: 26-32) week follow-up. Further follow-up assessments including the CAMPHOR score were performed 96 (IQR: 70-117) weeks, 178 (IQR: 156-200) weeks, and 250 (IQR: 237-275) weeks after the last intervention. From baseline to the last follow-up, CAMPHOR scores for symptoms, activity, and QoL improved from 9 (IQR: 6-14) to 3 (IQR: 0-9) (p < 0.001), 8 (IQR: 5-12) to 4 (IQR: 2-8) (p < 0.001), and 5 (IQR: 2-9) to 1 (IQR: 0-5) (p < 0.001). CONCLUSION BPA leads to long-lasting, significant improvement of symptoms, physical capacity, and QoL in inoperable CTEPH patients.
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Affiliation(s)
| | - Kristin Steinhaus
- University of Göttingen, Department of Cardiology and Pneumology, Göttingen, Germany
| | - Andreas Rolf
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Andreas Breithecker
- Kerckhoff Heart and Thorax Center, Department of Radiology, Bad Nauheim, Germany
- Gesundheitszentrum Wetterau, Department of Radiology, Bad Nauheim, Germany
| | - Miriam S D Adameit
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Steffen D Kriechbaum
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Bad Nauheim, Germany
| | - Moritz Haas
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
| | - Fritz Roller
- University of Giessen, Department of Radiology, Giessen, Germany
| | - Christian W Hamm
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Bad Nauheim, Germany
- University of Giessen, Department of Internal Medicine I, Division of Cardiology, Giessen, Germany
| | - H-Ardeschir Ghofrani
- Kerckhoff Heart and Thorax Center, Department of Pulmonology, Bad Nauheim, Germany
- Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL)
- Department of Medicine, Imperial College London, UK
| | - Eckhard Mayer
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Stefan Guth
- Kerckhoff Heart and Thorax Center, Department of Thoracic Surgery, Bad Nauheim, Germany
| | - Christoph Liebetrau
- Kerckhoff Heart and Thorax Center, Department of Cardiology, Bad Nauheim, Germany
- German Center for Cardiovascular Research (DZHK), partner site RheinMain, Bad Nauheim, Germany
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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Banaszkiewicz M, Kurzyna P, Kubikowska N, Mucha M, Rudnik A, Gąsecka A, Pietrasik A, Grabowski M, Jaguszewski MJ, Kasprzyk P, Kędzierski P, Ciećwierz D, Żuk G, Szwed P, Piłka M, Florczyk M, Kurzyna M, Darocha S. Emerging Role of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease-Insights from the 2022 ESC Guidelines. J Clin Med 2023; 12:5336. [PMID: 37629379 PMCID: PMC10455782 DOI: 10.3390/jcm12165336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
In this article, we discuss the topic of chronic thromboembolic pulmonary disease (CTEPD) and the growing role of balloon pulmonary angioplasty (BPA) in its treatment. We present the pathophysiology of CTEPD which arises from an incomplete resolution of thrombi in the pulmonary arteries and leads to stenosis and occlusion of the vessels. The article focuses mainly on the chronic thromboembolic pulmonary hypertension (CTEPH) subpopulation for which prognosis is very poor when left untreated. We describe a multimodal approach to treating CTEPH, including pulmonary endarterectomy (PEA), BPA, and pharmacological therapies. Additionally, the benefits of pharmacological pre-treatment before BPA and the technical aspects of the procedure itself are outlined. It is emphasized that BPA does not replace PEA but serves as a complementary treatment option for eligible patients. We summarized efficacy and treatment goals including an improvement in functional and biochemical parameters before and after BPA. Patients who received pre-treatment with riociguat prior to BPA exhibited a notable reduction in the occurrence of less severe complications. However, elderly patients are still perceived as an especially vulnerable group. It is shown that the prognosis of patients undergoing BPA is similar to PEA in the first years after the procedure but the long-term prognosis of BPA still remains unclear. The 2022 ESC/ERS guidelines highlight the significant role of BPA in the multimodal treatment of CTEPH, emphasizing its effectiveness and recommending its consideration as a therapeutic option for patients with CTEPD, both with and without pulmonary hypertension. This review summarizes the available evidence for BPA, patient selection, procedural details, and prognosis and discusses the potential future role of BPA in the management of CTEPH.
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Affiliation(s)
- Marta Banaszkiewicz
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Paweł Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Nina Kubikowska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Magda Mucha
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksander Rudnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | | | - Piotr Kasprzyk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Kędzierski
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Dariusz Ciećwierz
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Grzegorz Żuk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Szwed
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Piłka
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Florczyk
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Marcin Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Szymon Darocha
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
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Kanezawa M, Naito T, Shimokawahara H, Ogawa A, Matsubara H. Rescue balloon pulmonary angioplasty for refractory heart failure in chronic thromboembolic pulmonary hypertension complicated with takotsubo cardiomyopathy. J Cardiol Cases 2023; 28:79-82. [PMID: 37521576 PMCID: PMC10382977 DOI: 10.1016/j.jccase.2023.04.004] [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: 11/02/2022] [Revised: 04/05/2023] [Accepted: 04/17/2023] [Indexed: 08/01/2023] Open
Abstract
Balloon pulmonary angioplasty (BPA) seems promising for treating critically ill patients with chronic thromboembolic pulmonary hypertension (CTEPH) because of its less invasive and stepwise nature. However, there are only a few reports on rescue BPA. Herein, we present a case of CTEPH and takotsubo cardiomyopathy in an 82-year-old female. Despite treatment with catecholamines and intra-aortic balloon pumping, low output syndrome due to right heart failure with CTEPH and left heart failure with takotsubo cardiomyopathy did not improve. Therefore, rescue BPA for CTEPH was performed; this immediately improved the patient's hemodynamics. Learning objective Rescue balloon pulmonary angioplasty (BPA) is an option for critically ill patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) that requires immediate improvement of hemodynamics. BPA strategy initially aimed at partial improvement of pulmonary circulation would be useful in treating CTEPH complicated by refractory right and left heart failure due to coexisting left-sided heart disease.
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Affiliation(s)
- Misaki Kanezawa
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takanori Naito
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
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35
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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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Fernandes TM, Kim NH, Kerr KM, Auger WR, Fedullo PF, Poch DS, Yang J, Papamatheakis DG, Alotaibi M, Bautista MA, Pretorius VG, Madani MM. Distal vessel pulmonary thromboendarterectomy: Results from a single institution. J Heart Lung Transplant 2023; 42:1112-1119. [PMID: 37024310 DOI: 10.1016/j.healun.2023.02.1500] [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: 08/11/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries. METHODS Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group. RESULTS During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p = 0.039) and airway hemorrhage (3.0% vs 6.6%, p = 0.047) postoperatively. CONCLUSIONS Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.
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Affiliation(s)
- Timothy M Fernandes
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Nick H Kim
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Kim M Kerr
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - William R Auger
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Peter F Fedullo
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - David S Poch
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Jenny Yang
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California; San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Demosthenes G Papamatheakis
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Mona Alotaibi
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Marie A Bautista
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Victor G Pretorius
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Michael M Madani
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California.
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37
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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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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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Jain N, Perkins S, Maligireddy AR, Rosenfield K. Evolving Role and Clinical Evidence in the Global Practice of Balloon Pulmonary Angioplasty. Interv Cardiol Clin 2023; 12:417-427. [PMID: 37290844 DOI: 10.1016/j.iccl.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Balloon pulmonary angioplasty (BPA) was first described in 2001 and now has evolved into a class I indication for inoperable or residual chronic thromboembolic pulmonary hypertension. This review article aims to describe evidence from studies performed at various pulmonary hypertension (PH) centers across the globe, to better understand the role of BPA in chronic thromboembolic pulmonary disease with and without PH. Additionally, we hope to highlight innovations and the ever-changing safety and efficacy profile of BPA.
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Affiliation(s)
- Nishant Jain
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Sidney Perkins
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Kenneth Rosenfield
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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40
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Hosokawa K, Yamasaki Y, Abe K. Technical Considerations for Performing Safe and Effective Balloon Pulmonary Angioplasty in Patients with Chronic Thromboembolic Pulmonary Hypertension. Interv Cardiol Clin 2023; 12:367-380. [PMID: 37290840 DOI: 10.1016/j.iccl.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a late complication of acute pulmonary thromboembolism owing to incomplete clot dissolution in pulmonary artery. Pulmonary endarterectomy is the first-line treatment for CTEPH. However, 40% of patients are not candidates for surgery because of distal lesions or age. Balloon pulmonary angioplasty (BPA), a catheter-based intervention, is increasingly being used worldwide for treating inoperable CTEPH. Previous BPA strategy had a major concern of reperfusion pulmonary edema as a complication. However, recent refined strategies promise safe and effective BPA. Five-year survival rate after BPA is 90% for inoperable CTEPH, comparable with that of operable CTEPH.
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Affiliation(s)
- Kazuya Hosokawa
- Faculty of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan.
| | - Yuzo Yamasaki
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan
| | - Kohtaro Abe
- Faculty of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka 812-8582, Japan
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41
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Kazmirczak F, Prisco SZ, Knoper R, Huddleston S, Raveendran G, Pritzker M, Thenappan T, Prins KW, Gurevich S. Effect of Combination of Balloon Pulmonary Angioplasty and Medical Therapy on Reverse Right Ventricular Remodeling and Hemodynamics in Chronic Thromboembolic Pulmonary Hypertension. THE JOURNAL OF INVASIVE CARDIOLOGY 2023; 35:E312-E320. [PMID: 37410748 PMCID: PMC10428086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive and debilitating disorder that results from incomplete resolution of vascular obstructions resulting in pulmonary hypertension. Surgical pulmonary thromboendarterectomy (PTE) is the treatment of choice for CTEPH. Unfortunately, many CTEPH patients are ineligible for PTE or do not have access to an expert surgical center. Medical therapy imparts important symptomatic and exercise benefits for CTEPH patients, but it does not extend survival. Balloon pulmonary angioplasty (BPA) is an emerging transcatheter approach that is both safe and efficacious. However, the potential synergy between upfront BPA and medical therapy treatment approaches in patients with inoperable CTEPH is unknown. Here, we evaluated how the combination of BPA and medical therapy compared to medical therapy alone in a newly established BPA program. METHODS Twenty-one patients with inoperable or residual CTEPH were evaluated in this single-center observational study. Ten patients underwent upfront BPA and medical therapy while 11 patients were treated with medical therapy alone. Hemodynamic and echocardiographic assessments were performed at baseline and at least 1 month after completion of therapy. Continuous variables were compared using t-test or Mann-Whitney U-test. Categorical variables were analyzed with Chi squared and Fisher's exact test where appropriate. RESULTS Combination therapy significantly reduced mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), but medical therapy only significantly lowered PVR. Comprehensive echocardiographic analysis revealed a more robust reverse right ventricular (RV) remodeling effect and augmentation of RV function with combination therapy. At the end of study, the combination therapy group had lower mPAP and PVR and better RV function. Importantly, there were no significant adverse effects in patients treated with BPA. CONCLUSION Combination therapy significantly improves hemodynamics and RV function in inoperable CTEPH while carrying an acceptable risk profile, even in a newly developed program. Further studies comparing upfront combination therapy to medical therapy with larger, long-term, and randomized approaches should be considered.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sergey Gurevich
- University of Minnesota, 401 East River Parkway, VCRC 2nd Floor, Suite 269, Minneapolis, MN 55455 USA.
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Bashir R, Noory A, Oliveros E, Romero CM, Maruthi R, Mirza A, Lakhter V, Zhao H, Brisco-Bacik M, Vaidya A, Auger WR, Forfia P. Refined Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension: Initial Results of U.S. Regional Program. JACC. ADVANCES 2023; 2:100291. [PMID: 37501703 PMCID: PMC10373249 DOI: 10.1016/j.jacadv.2023.100291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 01/26/2023] [Accepted: 02/14/2023] [Indexed: 07/29/2023]
Abstract
Objectives We sought to evaluate the efficacy and safety of refined balloon pulmonary angioplasty (BPA) in the treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Background BPA is rapidly evolving therapeutic option for patients with nonsurgical CTEPH. There are few US studies that have reported on the outcomes of this novel therapeutic option. Methods This is a retrospective study of CTEPH patients that underwent BPA at Temple University Hospital. The primary efficacy endpoint was the change in pulmonary vascular resistance (PVR) after BPA as compared to baseline and the primary safety endpoint was the rate of hemoptysis within 24 hours. Secondary endpoints included death, WHO functional class, and 6-minute walk distance (6MWD). We used logistic regression to evaluate factors associated with a hemodynamic and functional response. Results A total of 211 BPA sessions were performed on 77 patients (average 2.7 ± 1.7 sessions/patient). After BPA the mean PVR improved by 26% (P<0.001) while the mean 6MWD improved by 71.7 meters (P <0.001) and WHO functional class improved by one functional class (P <0.001). Ten sessions (4.7%) were complicated by hemoptysis. The independent factors associated with a improved functional and hemodynamic response included the pre-procedural use of riociguat, reduce baseline PA compliance and > 3 BPA sessions per patient. Conclusion This single center study from the US showed that BPA with refined techniques in patients with CTEPH was safe and was associated with significant improvements in pulmonary hemodynamics and functional capacity.
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Affiliation(s)
- Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Ali Noory
- Department of Medicine, Cardiovascular Institute at Allegheny Health Network, Pittsburg, Pennsylvania, USA
| | - Estefania Oliveros
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Carlos Manuel Romero
- Department of Medicine, Lewis Katz School of Medicine Temple University, Philadelphia, Pennsylvania, USA
| | - Rohit Maruthi
- Department of Medicine, Lewis Katz School of Medicine Temple University, Philadelphia, Pennsylvania, USA
| | - Arslan Mirza
- Department of Medicine, Prairie Heart Institute of Illinois, Springfield, Illinois, USA
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Temple University, Philadelphia, Pennsylvania, USA
| | - Meredith Brisco-Bacik
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - Anjali Vaidya
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
| | - William R. Auger
- Department of Medicine, University of California, San Diego, California, USA
| | - Paul Forfia
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania, USA
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Jain N, Sheikh MA, Bajaj D, Townsend W, Krasuski R, Secemsky E, Chatterjee S, Moles V, Agarwal PP, Haft J, Visovatti SH, Cascino TM, Rosenfield K, Nallamothu BK, Mclaughlin VV, Aggarwal V. Periprocedural Complications With Balloon Pulmonary Angioplasty: Analysis of Global Studies. JACC Cardiovasc Interv 2023; 16:976-983. [PMID: 37100561 DOI: 10.1016/j.jcin.2023.01.361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/15/2022] [Accepted: 01/10/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique. OBJECTIVES The authors sought to better understand the evolution of BPA procedure-related complications over time. METHODS The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA. RESULTS This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01). CONCLUSIONS Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time.
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Affiliation(s)
- Nishant Jain
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Muhammad A Sheikh
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Divyansh Bajaj
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Whitney Townsend
- University of Michigan Taubman Health Sciences Library, Ann Arbor, Michigan, USA
| | - Richard Krasuski
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine (E.A.S.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Victor Moles
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott H Visovatti
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Thomas M Cascino
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brahmajee K Nallamothu
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Vallerie V Mclaughlin
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA.
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Tsubata H, Nakanishi N, Itatani K, Takigami M, Matsubara Y, Ogo T, Fukuda T, Matsuda H, Matoba S. Pulmonary artery blood flow dynamics in chronic thromboembolic pulmonary hypertension. Sci Rep 2023; 13:6490. [PMID: 37081116 PMCID: PMC10119089 DOI: 10.1038/s41598-023-33727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension is caused by incomplete resolution and organization of thrombi. Blood flow dynamics are involved in thrombus formation; however, only a few studies have reported on pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension. Furthermore, the effects of treatment interventions on pulmonary artery blood flow dynamics are not fully understood. The aim of the study was to evaluate pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension before and after pulmonary endarterectomy and balloon pulmonary angioplasty, using computational fluid dynamics. We analyzed patient-specific pulmonary artery models of 10 patients with chronic thromboembolic pulmonary hypertension and three controls using computational fluid dynamics. In patients with chronic thromboembolic pulmonary hypertension, flow velocity and wall shear stress in the pulmonary arteries were significantly decreased, and the oscillatory shear index and blood stagnation volume were significantly increased than in controls. Pulmonary endarterectomy induced redistribution of pulmonary blood flow and improved blood flow dynamics in the pulmonary artery. Balloon pulmonary angioplasty improved pulmonary blood flow disturbance, decreased blood flow stagnation, and increased wall shear stress, leading to vasodilatation of the distal portion of the pulmonary artery following balloon pulmonary angioplasty treatment.
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Affiliation(s)
- Hideo Tsubata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan.
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masao Takigami
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Yuki Matsubara
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Vascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
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Lang IM. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Clinical Outcomes. Eur Cardiol 2023. [DOI: 10.15420/ecr.2022.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare major vessel pulmonary vascular disease that is characterised by fibrotic obstructions deriving from an organised clot. Recent advances in treatments for CTEPH have significantly improved outcomes. Apart from classical surgical pulmonary endarterectomy, balloon pulmonary angioplasty (BPA) and vasodilator drugs that were tested in randomised controlled trials of non-operable patients are now available. In Europe, CTEPH affects males and females equally. In the first European CTEPH Registry, women with CTEPH underwent pulmonary endarterectomy less frequently than men, especially at low-volume centres. In Japan, CTEPH is more common in females and is predominantly treated by BPA. More data on gender-specific outcomes are expected from the results of the International BPA Registry (NCT03245268).
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Kuramoto K, Ogawa A, Kiyama K, Matsubara H, Ohno Y, Fuchikami C, Hayashi K, Kosugi K, Kuwano K. Antiproliferative effect of selexipag active metabolite MRE-269 on pulmonary arterial smooth muscle cells from patients with chronic thromboembolic pulmonary hypertension. Pulm Circ 2023; 13:e12231. [PMID: 37180827 PMCID: PMC10173849 DOI: 10.1002/pul2.12231] [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: 12/21/2022] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 05/16/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a group 4 pulmonary hypertension (PH) characterized by nonresolving thromboembolism in the central pulmonary artery and vascular occlusion in the proximal and distal pulmonary artery. Medical therapy is chosen for patients who are ineligible for pulmonary endarterectomy or balloon pulmonary angioplasty or who have symptomatic residual PH after surgery or intervention. Selexipag, an oral prostacyclin receptor agonist and potent vasodilator, was approved for CTEPH in Japan in 2021. To evaluate the pharmacological effect of selexipag on vascular occlusion in CTEPH, we examined how its active metabolite MRE-269 affects platelet-derived growth factor-stimulated pulmonary arterial smooth muscle cells (PASMCs) from CTEPH patients. MRE-269 showed a more potent antiproliferative effect on PASMCs from CTEPH patients than on those from normal subjects. DNA-binding protein inhibitor (ID) genes ID1 and ID3 were found by RNA sequencing and real-time quantitative polymerase chain reaction to be expressed at lower levels in PASMCs from CTEPH patients than in those from normal subjects and were upregulated by MRE-269 treatment. ID1 and ID3 upregulation by MRE-269 was blocked by co-incubation with a prostacyclin receptor antagonist, and ID1 knockdown by small interfering RNA transfection attenuated the antiproliferative effect of MRE-269. ID signaling may be involved in the antiproliferative effect of MRE-269 on PASMCs. This is the first study to demonstrate the pharmacological effects on PASMCs from CTEPH patients of a drug approved for the treatment of CTEPH. Both the vasodilatory and the antiproliferative effect of MRE-269 may contribute to the efficacy of selexipag in CTEPH.
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Affiliation(s)
- Kazuya Kuramoto
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
| | - Aiko Ogawa
- Department of Clinical ScienceNational Hospital Organization Okayama Medical CenterOkayamaJapan
| | - Kazuko Kiyama
- Department of Clinical ScienceNational Hospital Organization Okayama Medical CenterOkayamaJapan
| | - Hiromi Matsubara
- Department of CardiologyNational Hospital Organization Okayama Medical CenterOkayamaJapan
| | - Yuji Ohno
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
| | - Chiaki Fuchikami
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
| | - Kyota Hayashi
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
| | - Keiji Kosugi
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
| | - Keiichi Kuwano
- Discovery Research LaboratoriesNippon Shinyaku Co., LtdKyotoJapan
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New Drugs and Therapies in Pulmonary Arterial Hypertension. Int J Mol Sci 2023; 24:ijms24065850. [PMID: 36982922 PMCID: PMC10058689 DOI: 10.3390/ijms24065850] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/12/2023] [Accepted: 03/14/2023] [Indexed: 03/22/2023] Open
Abstract
Pulmonary arterial hypertension is a chronic, progressive disorder of the pulmonary vasculature with associated pulmonary and cardiac remodeling. PAH was a uniformly fatal disease until the late 1970s, but with the advent of targeted therapies, the life expectancy of patients with PAH has now considerably improved. Despite these advances, PAH inevitably remains a progressive disease with significant morbidity and mortality. Thus, there is still an unmet need for the development of new drugs and other interventional therapies for the treatment of PAH. One shortcoming of currently approved vasodilator therapies is that they do not target or reverse the underlying pathogenesis of the disease process itself. A large body of evidence has evolved in the past two decades clarifying the role of genetics, dysregulation of growth factors, inflammatory pathways, mitochondrial dysfunction, DNA damage, sex hormones, neurohormonal pathways, and iron deficiency in the pathogenesis of PAH. This review focuses on newer targets and drugs that modify these pathways as well as novel interventional therapies in PAH.
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Carlozzi LN, Lee J, Barros LM, Buber Y, Chen DL, Mulligan M, Ordovas K, Ralph DD, Rayner SG, Leary PJ, Steinberg ZL. Establishing a balloon pulmonary angioplasty program for chronic thromboembolic pulmonary hypertension: A United States single-center experience. Respir Med 2023; 211:107215. [PMID: 36934856 DOI: 10.1016/j.rmed.2023.107215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) is a less invasive treatment alternative for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are unable to move forward with pulmonary thromboendarterectomy. This report describes a single-center experience with a nascent BPA program in the United States (US). METHODS All patients who underwent BPA between August 2018-2021 were included in this retrospective, single-center observational cohort. Pre- and post-procedure clinical information was collected, along with procedural characteristics. RESULTS Thirty patients began their BPA series during the study period. The majority of patients had segmental disease (n = 25, 83.3%). A total of 135 BPA procedures were performed on 417 segments. On average, patients completed 4.5 sessions and the majority of patients (n = 23, 76.7%) underwent more than 2. There were 24 episodes of hemoptysis and 20 procedural events that required treatment, typically with either heparin reversal or balloon tamponade. Of 26 participants with completed series, mean PA pressure (-6 mmHg, 95% CI -9 to -4 mmHg, p = 0.0001), PVR (-1.9 Wood units, 95% CI -2.9 to -1.0, p = 0.0002), and pulmonary compliance (-1.0 mL/mmHg, 95% CI -1.5 to -0.5, p = 0.0002) improved. Improvement was also seen in NYHA functional classification and walk distance (p = 0.01). Two deaths occurred, with one death peri-procedurally. CONCLUSION This paper describes an early experience with BPA at a single US center. Improvement in non-invasive and invasive metrics were seen without adding a significant morbidity to an already high-risk patient population.
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Affiliation(s)
| | - Josh Lee
- Critical Care, Pulmonary and Sleep Associates, Denver, CO, USA
| | - Lia M Barros
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Yonatan Buber
- University of Washington, Division of Cardiology, USA
| | | | - Michael Mulligan
- University of Washington, Division of Cardiothoracic Surgery, USA
| | - Karen Ordovas
- University of Washington, Department of Radiology, USA
| | - David D Ralph
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Samuel G Rayner
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Peter J Leary
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA; University of Washington, Department of Epidemiology, USA
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Cullivan S, Gaine S, Sitbon O. New trends in pulmonary hypertension. Eur Respir Rev 2023; 32:32/167/220211. [PMID: 36813291 PMCID: PMC9949382 DOI: 10.1183/16000617.0211-2022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/12/2022] [Indexed: 02/24/2023] Open
Abstract
Pulmonary hypertension (PH) is a prevalent disease of the pulmonary vasculature that is characterised by considerable morbidity and mortality. Substantial efforts have been made in recent years to improve disease recognition, diagnosis and management, and this is reflected in current guidelines. The haemodynamic definition of PH has been revised and a definition for exercise PH has been provided. Risk stratification has been refined and the importance of comorbidities and phenotyping have been highlighted. These changes provide an opportunity to potentially identify pulmonary vascular disease at an earlier stage and to enhance patient-centred, goal-orientated treatment decisions. A promising fourth treatment pathway for pulmonary arterial hypertension and potential targeted therapies for group 3 PH are on the horizon, concepts which seemed inconceivable only a few years ago. Beyond medication, there is a greater appreciation for the importance of supervised training in stable PH and the possible role of interventional therapies in select cases. The landscape of PH is changing and it is characterised by progress, innovation and opportunities. In this article, we highlight some of the new trends in PH, with a specific focus on the revised European Society of Cardiology/European Respiratory Society 2022 guidelines for the diagnosis and management of PH.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Olivier Sitbon
- Department of Respiratory and Intensive Care Medicine, CHU Bicêtre, Paris-Saclay University, INSERM URM_S999, Le Kremlin-Bicêtre, France
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Surgical and Device Interventions in the Treatment of Chronic Thromboembolic Disease. Pulm Ther 2023; 9:207-221. [PMID: 36800165 DOI: 10.1007/s41030-023-00217-z] [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: 12/10/2022] [Accepted: 01/19/2023] [Indexed: 02/18/2023] Open
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is characterized by unresolved clot burden in large pulmonary arteries, obstructive disease in smaller arteries, and increased downstream clot burden. This occurs in the setting of abnormal fibrinolysis or hematological disorders. Up to 50% of patients in some studies are unaware of a self-history of a deep venous thrombosis or pulmonary embolism. Ultimately, they present with symptoms of pulmonary hypertension (PH), which can result in right heart failure (RHF). Pulmonary endarterectomy (PEA) is curative, though many patients have prohibitive surgical risk or surgically inaccessible disease, warranting other interventions such as balloon pulmonary angioplasty (BPA) and medical therapy. Rarely, other treatment options may be implemented. We focus this review on PEA and BPA, with an overview of the history of CTEPD and the evolution of these procedures. We will briefly discuss other treatment modalities.
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