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Suruga K, Shimokawahara H, Miyagi A, Sugiyama Y, Suetomi T, Ogawa A, Matsubara H. Flow Grade-Based Success Rates, Complication Rates, and Balloon Pulmonary Angioplasty Patency for Total Occlusions. Can J Cardiol 2024; 40:625-633. [PMID: 38081510 DOI: 10.1016/j.cjca.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The number of successfully recanalized total occlusions affects hemodynamic improvement after balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to clarify the current efficacy, patency, and success rate of BPA for total occlusions. METHODS Between April 2016 and August 2021, 178 BPAs were performed in 100 patients with CTEPH and total occlusions. The primary success and subsequent patency rates immediately before the second BPA procedure (follow-up) were compared between the segmental and subsegmental groups, based on the flow grade, which was defined as follows: 0, no reperfusion; 1, minimal reperfusion; 2, partial reperfusion; and 3, complete reperfusion. RESULTS Total occlusions were mainly located in the right lung (70%) and lower lobes (48%). The primary success rate was 88%, with significant improvements in oxygenation, hemodynamic parameters, and 6-minute walk test. The primary flow grade did not differ between groups. However, the proportion of lesions with a flow grade of 2 or 3 at follow-up was significantly higher in the subsegmental group than in the segmental group (84% vs 45%, respectively; P < 0.01). In multivariate analysis, flow grade in the acute phase (odds ratio [OR], 46.9; 95% confidence interval [CI], 12.54-176.78; P < 0.01) and subsegmental lesions (OR, 13.8; 95% CI, 3.24-58.94; P < 0.01) were independently associated with better patency (flow grade of 2 or 3) at follow-up. CONCLUSIONS Total occlusions can be safely and effectively treated with BPA. BPA for total occlusions may be preferable for subsegmental over segmental lesions.
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Affiliation(s)
- Kazuki Suruga
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan.
| | - Ayane Miyagi
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Yoichi Sugiyama
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Takeshi Suetomi
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Aiko Ogawa
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology and Clinical Science, NHO Okayama Medical Center, Okayama, Japan
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Madani MM. Acute Kidney Injury Post Pulmonary Thromboendarterectomy: Is It a Valid Concern? A Word of Caution. Ann Thorac Surg 2024; 117:318-319. [PMID: 36084695 DOI: 10.1016/j.athoracsur.2022.08.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 08/27/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, 9300 Campus Point Dr, #7892, Mail Code 7892, La Jolla, CA 92037-7892.
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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Yamaguchi T, Ehara S, Yoshida H, Himoto D, Izuta S, Hayashi O, Hayashi H, Ogawa M, Shibata A, Yamazaki T, Izumiya Y, Fukuda D. Quantification of pulmonary perfusion using LSIM-CT correlates with pulmonary hemodynamics in patients with CTEPD. Front Cardiovasc Med 2023; 10:1237296. [PMID: 38028450 PMCID: PMC10654960 DOI: 10.3389/fcvm.2023.1237296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lung subtraction iodine mapping (LSIM)-CT is a clinically useful technique that can visualize pulmonary mal-perfusion in patients with chronic thromboembolic pulmonary disease (CTEPD). However, little is known about the associations of LSIM images with hemodynamic parameters of patients with CTEPD. This study investigates a parameter of LSIM images associated with mean pulmonary arterial pressure (mPAP) and validates the association between pulmonary vascular resistance, right atrial pressure, cardiac index, and exercise capacity in patients with CTEPD. Methods This single-center, prospective, observational study involved 30 patients diagnosed with CTEPD using lung perfusion scintigraphy. To examine the correlation of decreased pulmonary perfusion area (DPA) with mPAP, areas with 0-10, 0-15, 0-20, and 0-30 HU in lung subtraction images were adopted in statistical analysis. The DPA to total lung volume ratio (DPA ratio, %) was calculated as the ratio of each DPA volume to the total lung volume. To assess the correlation between DPA ratios of 0-10, 0-15, 0-20, and 0-30 HU and mPAP, Spearman's rank correlation coefficient was used. Results The DPA ratio of 0-10 HU had the most preferable correlation with mPAP than DPA ratios of 0-15, 0-20, and 0-30 HU (ρ = 0.440, P = 0.015). The DPA ratio of 0-10 HU significantly correlates with pulmonary vascular resistance (ρ = 0.445, P = 0.015). The receiver operating characteristic curve analysis indicated that the best cutoff value of the DPA ratio of 0-10 HU for the prediction of an mPAP of ≥30 mmHg was 8.5% (AUC, 0.773; 95% CI, 0.572-0.974; sensitivity, 83.3%; specificity, 75.0%). Multivariate linear regression analysis, which was adjusted for the main pulmonary arterial to ascending aortic diameter ratio and right ventricular to left ventricular diameter ratio, indicated that the DPA ratio of 0-10 HU was independently and significantly associated with mPAP (B = 89.7; 95% CI, 46.3-133.1, P < 0.001). Conclusion The DPA ratio calculated using LSIM-CT is possibly useful for estimating the hemodynamic status in patients with CTEPD.
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Affiliation(s)
- Tomohiro Yamaguchi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shoichi Ehara
- Department of Intensive Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Himoto
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Shinichiro Izuta
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Ou Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroya Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mana Ogawa
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Shibata
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takanori Yamazaki
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Reimann L, Mayer L, Schneider SR, Schwarz EI, Müller J, Titz A, Furian M, Carta AF, Etienne H, Battilana B, Saxer S, Pfammatter T, Frauenfelder T, Opitz I, Ulrich S, Lichtblau M. Change in Right-to-Left Shunt Fraction in Patients with Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Endarterectomy. J Cardiovasc Dev Dis 2023; 10:442. [PMID: 37998500 PMCID: PMC10672130 DOI: 10.3390/jcdd10110442] [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: 09/05/2023] [Revised: 10/06/2023] [Accepted: 10/20/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) with accessible lesions. Breathing pure oxygen (hyperoxia) during right heart catheterization (RHC) allows for the calculation of the right-to-left shunt fraction (Qs/Qt). In the absence of intracardiac shunt, Qs/Qt can be used as a marker of ventilation-perfusion mismatch in patients with CTEPH. This study involved investigating Qs/Qt after PEA and its relation to other disease-specific outcomes. STUDY DESIGN AND METHODS This study is a retrospective study that focuses on patients with operable CTEPH who had Qs/Qt assessment during RHC before and 1 year after PEA. Additionally, 6 min walking distance (6MWD), WHO functional class (WHO-FC), and NT-proBNP were assessed to calculate a four-strata risk score. RESULTS Overall, 16 patients (6 females) with a median age of 66 years (quartiles 55; 74) were included. After PEA, an improvement in mean pulmonary artery pressure (38 [32; 41] to 24 [18; 28] mmHg), pulmonary vascular resistance (5.7 [4.0; 6.8] to 2.5 [1.4; 3.8] WU), oxygen saturation (92 [88; 93]% to 94 [93; 95]%), WHO-FC, and risk score was observed (all p < 0.05). No improvement in median Qs/Qt could be detected (13.7 [10.0; 17.5]% to 13.0 [11.2; 15.6]%, p = 0.679). A total of 7 patients with improved Qs/Qt had a significant reduction in risk score compared to those without improved Qs/Qt. CONCLUSION PEA did not alter Qs/Qt assessed after 1 year in operable CTEPH despite an improvement in hemodynamics and risk score, potentially indicating a persistent microvasculopathy. In patients whose shunt fraction improved with PEA, the reduced shunt was associated with an improvement in risk score.
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Affiliation(s)
- Lena Reimann
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Laura Mayer
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Simon Raphael Schneider
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Esther I. Schwarz
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Julian Müller
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Anna Titz
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Arcangelo F. Carta
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Harry Etienne
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Bianca Battilana
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Stéphanie Saxer
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
- Department of Health, Eastern Switzerland University of Applied Sciences, 9001 St. Gallen, Switzerland
| | - Thomas Pfammatter
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
| | - Mona Lichtblau
- Department of Pulmonology, University Hospital Zurich, University of Zurich, 8091 Zurich, Switzerland
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Kauliņš R, Rudzītis A, Lejnieks A, Kigitoviča D, Skride A. Baseline Clinical Characteristics and Incidence of Chronic Thromboembolic Pulmonary Hypertension Patients in Latvia, 2019-2020. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1426. [PMID: 37629717 PMCID: PMC10456735 DOI: 10.3390/medicina59081426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023]
Abstract
Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and progressive condition; however, the true characteristics of CTEPH are still unknown, as notable regional variations exist in terms of patients' age, baseline hemodynamic data, and management choices. This report aims to investigate the baseline clinical characteristics, incidence, and risk factors associated with CTEPH patients in Latvia from 2019 to 2020. Methods: The data were analyzed from a prospective, nationwide, Latvian pulmonary hypertension registry for incident CTEPH cases. The patients' clinical characteristics were assessed at the time of diagnosis. Results: During the course of this study, a cohort of 13 patients with CTEPH were included for analysis. Among the enrolled CTEPH patients, most exhibited low exercise and functional capacity, with a median (±IQR) 6 min walk distance of 300.0 (±150.0) m. The median values (±IQR) for mean pulmonary artery pressure and pulmonary vascular resistance were 40.0 ± 13.0 mmHg and 7.35 ± 2.82 Wood units, respectively. The most common risk factors for CTEPH were a history of acute pulmonary embolism and a blood group other than O. Conclusions: The findings of this report revealed the characteristics of the Latvian CTEPH population, indicating that a significant proportion of patients are elderly individuals with multiple comorbidities.
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Affiliation(s)
- Ričards Kauliņš
- Department of Internal Diseases, Riga Stradiņš University, LV-1079 Riga, Latvia
| | - Ainārs Rudzītis
- Department of Internal Diseases, Riga Stradiņš University, LV-1079 Riga, Latvia
- Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, LV-1002 Riga, Latvia
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradiņš University, LV-1079 Riga, Latvia
- Department of Internal Diseases, Riga East Clinical University Hospital, LV-1079 Riga, Latvia
| | - Dana Kigitoviča
- Department of Internal Diseases, Riga Stradiņš University, LV-1079 Riga, Latvia
| | - Andris Skride
- Department of Internal Diseases, Riga Stradiņš University, LV-1079 Riga, Latvia
- Department of Rare Diseases, Pauls Stradiņš Clinical University Hospital, LV-1002 Riga, Latvia
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7
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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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Ishida K, Kohno H, Matsuura K, Sugiura T, Sanada TJ, Naito A, Shigeta A, Suda R, Sekine A, Masuda M, Sakao S, Tanabe N, Tatsumi K, Matsumiya G. Impact of residual pulmonary hypertension on long-term outcomes after pulmonary endarterectomy in the modern era. Pulm Circ 2023; 13:e12215. [PMID: 37051490 PMCID: PMC10084236 DOI: 10.1002/pul2.12215] [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: 05/27/2022] [Revised: 03/15/2023] [Accepted: 03/25/2023] [Indexed: 04/14/2023] Open
Abstract
Residual pulmonary hypertension (PH) negatively impacts long-term results following pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We sought to reveal whether modern PH therapy with PH-targeted medicine and balloon pulmonary angioplasty (BPA) improved long-term results of residual PH after PEA. Long-term findings of 80 patients who survived PEA between 2011 and 2019 were retrospectively investigated. One month after PEA, 30 patients developed residual PH defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg, of whom 23 were treated by PH-targeted medicine and 9 by BPA. Patients with residual PH acquired considerably better functional status and exercise capacity after PEA, however, exhibited significantly worse survival rates than those without. Eleven patients died during follow-up: 8 patients with residual PH and 3 controls. Among patients with residual PH, the deceased had a significantly lower %decrease in mPAP from 1 month to 1 year following PEA (7.4 [-32.6 to 8.0] % vs. 10.4 [3.7-27.8] %, p = 0.03) and higher mPAP at 1 year following PEA (39.5 [33.25-42.5] vs. 27 [26-34] mmHg, p < 0.01) despite PH-targeted medicine than the survived. No patients passed away from right heart failure, and there was no difference between the groups in CTEPH-related mortality. Modern PH therapy was used to address the majority of residual PH. Long-term survival after PEA was negatively impacted by residual PH, but it appeared that long-term mortality was also correlated with unrelieved residual PH despite PH-targeted medicine. Modern PH therapy may have enhanced functional status and excercise capacity, and averted fatal right heart failure.
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Affiliation(s)
- Keiichi Ishida
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Hiroki Kohno
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Kaoru Matsuura
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Toshihiko Sugiura
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Takayuki J. Sanada
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Akira Naito
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Ayako Shigeta
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Rika Suda
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Ayumi Sekine
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Masahisa Masuda
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Seiichiro Sakao
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Nobuhiro Tanabe
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Koichiro Tatsumi
- Department of RespirologyChiba University Graduate School of MedicineChibaChiba‐shiJapan
| | - Goro Matsumiya
- Department of Cardiovascular SurgeryChiba University Graduate School of MedicineChibaChiba‐shiJapan
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9
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Hadinnapola CM, Southwood M, Hernández-Sánchez J, Bunclark K, Newnham M, Swietlik EM, Cannon J, Preston SD, Sheares K, Taboada D, Screaton N, Jenkins DP, Morrell NW, Toshner M, Pepke-Zaba J. Angiopoietin 2 and hsCRP are associated with pulmonary hemodynamics and long-term mortality respectively in CTEPH-Results from a prospective discovery and validation biomarker study. J Heart Lung Transplant 2023; 42:398-405. [PMID: 36609091 DOI: 10.1016/j.healun.2022.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 08/17/2022] [Accepted: 08/27/2022] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed disease of uncertain etiology. Altered endothelial homeostasis, defective angiogenesis and inflammation are implicated. Angiopoietin 2 (Ang2) impairs acute thrombus resolution and is associated with vasculopathy in idiopathic pulmonary arterial hypertension. METHODS We assessed circulating proteins associated with these processes in serum from patients with CTEPH (n = 71) before and after pulmonary endarterectomy (PEA), chronic thromboembolic pulmonary disease without pulmonary hypertension (CTEPD, n = 9) and healthy controls (n = 20) using Luminex multiplex arrays. Comparisons between groups were made using multivariable rank regression models. Ang2 and high-sensitivity C-reactive protein (hsCRP) were measured in a larger validation dataset (CTEPH = 277, CTEPD = 26). Cox proportional hazards models were used to identify markers predictive of survival. RESULTS In CTEPH patients, Ang2, interleukin (IL) 8, tumor necrosis factor α, and hsCRP were elevated compared to controls, while vascular endothelial growth factor (VEGF) c was lower (p < 0.05). Ang2 fell post-PEA (p < 0.05) and was associated with both pre- and post-PEA pulmonary hemodynamic variables and functional assessments (p < 0.05). In the validation dataset, Ang2 was significantly higher in CTEPH compared to CTEPD. Pre-operative hsCRP was an independent predictor of mortality. CONCLUSIONS We hypothesize that CTEPH patients have significant distal micro-vasculopathy and consequently high circulating Ang2. Patients with CTEPD without pulmonary hypertension have no discernible distal micro-vasculopathy and therefore have low circulating Ang2. This suggests Ang2 may be critical to CTEPH disease pathogenesis (impaired thrombus organization and disease severity).
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Affiliation(s)
- Charaka M Hadinnapola
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Norfolk and Norwich University Hospital, University of East Anglia, Colney Lane, Norwich, UK
| | - Mark Southwood
- Department of Histopathology, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Jules Hernández-Sánchez
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; MRC Biostatistics Unit, Cambridge Institute of Public Health, Cambridge Biomedical Campus, Cambridge, UK
| | - Katherine Bunclark
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Michael Newnham
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK; Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, UK
| | - Emilia M Swietlik
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK; Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - John Cannon
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Stephen D Preston
- Department of Histopathology, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Karen Sheares
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Nicholas Screaton
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - David P Jenkins
- Department of Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge Biomedical Campus, Cambridge, UK
| | - Mark Toshner
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge Biomedical Campus Cambridge, Cambridge, UK.
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10
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Milne KM, James MD, Smyth RM, Vincent SG, Singh N, D'Arsigny CL, de-Torres JP, de Wit K, Johri A, Neder JA, O'Donnell DE, Phillips DB. Neurophysiological mechanisms of exertional dyspnea in post-pulmonary embolism syndrome. J Appl Physiol (1985) 2023; 134:667-677. [PMID: 36701483 DOI: 10.1152/japplphysiol.00677.2022] [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: 01/27/2023] Open
Abstract
Following pulmonary embolism (PE), a third of patients develop persistent dyspnea, which is commonly termed the post-PE syndrome. The neurophysiological underpinnings of exertional dyspnea in patients with post-PE syndrome without pulmonary hypertension (PH) are unclear. Thus, the current study determined if abnormally high inspiratory neural drive (IND) due, in part, to residual pulmonary gas-exchange abnormalities, was linked to heightened exertional dyspnea and exercise limitation, in such patients. Fourteen participants with post-PE syndrome (without resting PH) and 14 age-, sex-, and body mass index-matched healthy controls undertook pulmonary function testing and a symptom-limited cycle cardiopulmonary exercise test with measurements of IND (diaphragmatic electromyography), ventilatory requirements for CO2 (V̇e/V̇co2), and perceived dyspnea intensity (modified Borg 0-10 scale). Post-PE (vs. control) had a reduced resting transfer coefficient for carbon monoxide (KCO: 84 ± 15 vs. 104 ± 14%pred, P < 0.001) and peak oxygen uptake (V̇o2peak) (76 ± 14 vs. 124 ± 28%pred, P < 0.001). IND and V̇e/V̇co2 were higher in post-PE than controls at standardized submaximal work rates (P < 0.05). Dyspnea increased similarly in both groups as a function of increasing IND but was higher in post-PE at standardized submaximal work rates (P < 0.05). High IND was associated with low KCO (r = -0.484, P < 0.001), high V̇e/V̇co2 nadir (r = 0.453, P < 0.001), and low V̇o2peak (r = -0.523, P < 0.001). In patients with post-PE syndrome, exercise IND was higher than controls and was associated with greater dyspnea intensity. The heightened IND and dyspnea in post-PE, in turn, were strongly associated with low resting KCO and high exercise V̇e/V̇co2, which suggest important pulmonary gas-exchange abnormalities in this patient population.NEW & NOTEWORTHY This study is the first to show that increased exertional dyspnea in patients with post-pulmonary embolism (PE) syndrome, without overt pulmonary hypertension, was strongly associated with elevated inspiratory neural drive (IND) to the diaphragm during exercise, compared with healthy controls. The greater IND was associated with impairments in pulmonary gas exchange and significant deconditioning. Our results help to explain why many patients with post-PE syndrome report significant dyspnea at relatively low levels of physical activity.
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Affiliation(s)
- Kathryn M Milne
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada.,Centre for Heart Lung Innovation, Providence Health Care Research Institute, University of British Columbia St. Paul's Hospital, Vancouver, British Columbia, Canada.,Division of Respiratory Medicine, Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew D James
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Reginald M Smyth
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Sandra G Vincent
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Namisha Singh
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Christine L D'Arsigny
- Department of Critical Care Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Juan P de-Torres
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Amer Johri
- Division of Cardiology, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - J Alberto Neder
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Denis E O'Donnell
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada
| | - Devin B Phillips
- Respiratory Investigation Unit, Department of Medicine, Queen's University and Kingston Health Sciences Centre Kingston General Hospital Campus, Kingston, Ontario, Canada.,School of Kinesiology and Health Science, Faculty of Health, York University, Toronto, Ontario, Canada
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11
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Shimahara Y, Suzuki S, Fujiyoshi T, Honda S, Koizumi N, Yamashita J, Sasaki Y, Ito R, Takahashi L, Nakai M, Ogino H. Balloon pulmonary angioplasty followed by pulmonary endarterectomy: Combination treatment for high-surgical-risk patients with chronic thromboembolic pulmonary hypertension. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 36:7056648. [PMID: 36825847 PMCID: PMC9985147 DOI: 10.1093/icvts/ivad031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 01/11/2023] [Accepted: 02/24/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES Our goal was to evaluate the combined effects of balloon pulmonary angioplasty (BPA) followed by pulmonary endarterectomy (PEA) to treat high-surgical-risk patients with chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This study included 58 patients with CTEPH who had pulmonary vascular resistance of ≥1000 dyn·s/cm5, mean pulmonary arterial pressure (mPAP) of ≥45 mmHg or mPAP of 38-44 mmHg with comorbidities. Of these, 21 patients underwent the combined therapy of BPA followed by PEA (BPA group) and 37 underwent direct PEA (non-BPA group). Preoperative and postoperative results were compared between the 2 groups. An early postoperative composite event comprised the postoperative use of extracorporeal membrane oxygenation or intra-aortic balloon pump, in-hospital death, rescue BPA, prolonged ventilation, tracheostomy, prolonged stay in the intensive care unit, deep sternal wound infection and cerebral infarction. RESULTS Before the first intervention (before BPA or direct PEA), patients in the BPA group had a higher mPAP than those in the non-BPA group. After undergoing BPA before PEA, the BPA group demonstrated significantly decreased mPAP and pulmonary vascular resistance (43 vs 52 mmHg, P < 0.001; 636 vs 965 dyn·s/cm5, P = 0.003, respectively) and significantly increased cardiac output (4.1 vs 3.5 l/min, P = 0.041). Notably, the number of patients with the early postoperative composite event was significantly lower in the BPA group than in the non-BPA group (4.8% vs 35.1%, P = 0.011). CONCLUSIONS Compared with direct PEA, the combination therapy of BPA followed by PEA can be a feasible and effective risk-reduction strategy for high-surgical-risk patients with CTEPH.
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Affiliation(s)
- Yusuke Shimahara
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Shun Suzuki
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiki Fujiyoshi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Sayaka Honda
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Nobusato Koizumi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Yuichi Sasaki
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Ryosuke Ito
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Lisa Takahashi
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Michikazu Nakai
- Department of medical and health information management, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Ogino
- Corresponding Author. Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan, 6-7-1 Nishishinjuku Shinjuku-ku Tokyo 160-0023 Japan. Tel: (81)3-3342-6111; fax: (81)3-3342-6193; e-mail: (H. Ogino)
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12
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Daigo K, Katsumata Y, Esaki K, Iwasawa Y, Ichihara G, Miura K, Shirakawa K, Sato Y, Sato K, Fukuda K. Predictors of Improvement in Exercise Tolerance After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e8137. [PMID: 36718876 PMCID: PMC9973625 DOI: 10.1161/jaha.122.027395] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 02/01/2023]
Abstract
Background Balloon pulmonary angioplasty (BPA) improves exercise tolerance and hemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension. However, it is still unclear which patient characteristics contribute to the improvement in exercise tolerance after BPA in chronic thromboembolic pulmonary hypertension. Methods and Results We retrospectively analyzed 126 patients with chronic thromboembolic pulmonary hypertension (aged 63±14 years; female, 65%) who underwent BPA without concomitant programmed exercise rehabilitation at Keio University between November 2012 and April 2018. Hemodynamic data and 6-minute walk distance (6MWD), as a measure of exercise tolerance, were evaluated before and 1 year after BPA. The clinical characteristics that contributed to improvement in exercise tolerance were elucidated. The 6MWD significantly increased from 372.0 m (256.5-431.3) to 462.0 m (378.8-537.0) 1 year after BPA (P<0.001). The improvement rate in the 6MWD after BPA exhibited a good correlation with age, height, mean pulmonary artery pressure, and 6MWD at baseline (Spearman rank correlation coefficients=-0.28, 0.24, -0.40, and 0.44, respectively). Additional multivariable linear regression analysis revealed that young age, tall height, high mean pulmonary artery pressure, short 6MWD at baseline, and high lung capacity at baseline were significant predictors of the improvement in 6MWD by BPA (standardized partial regression coefficient -0.39, 0.22, 0.19, -0.62, and 0.25, P<0.001, 0.007, 0.011, <0.001, and <0.001, respectively). Conclusions BPA without concomitant programmed exercise rehabilitation significantly improves exercise tolerance. This was particularly true in young patients with high stature, high mean pulmonary artery pressure, short 6MWD, and lung capacity at the time of diagnosis.
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Affiliation(s)
- Kyohei Daigo
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Kosho Esaki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yuji Iwasawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Genki Ichihara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kotaro Miura
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kohsuke Shirakawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yasunori Sato
- Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of MedicineTokyoJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
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13
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Nishihara T, Shimokawahara H, Ogawa A, Naito T, Une D, Mukai T, Niiya H, Ito H, Matsubara H. Comparison of the safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with surgically accessible and inaccessible lesions. J Heart Lung Transplant 2023; 42:786-794. [PMID: 36792382 DOI: 10.1016/j.healun.2023.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/27/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension, not all patients are eligible. While balloon pulmonary angioplasty is an alternative for such patients, its efficacy and safety may differ between patients with and without surgically accessible lesions. METHODS This study involved 344 patients treated with balloon pulmonary angioplasty who were ineligible for pulmonary endarterectomy. Based on the angiographical lesion location, patients were divided into the surgically accessible (Group 1) and inaccessible (Group 2) groups, and percent changes in hemodynamics and clinical parameters before and after balloon pulmonary angioplasty were investigated. We also conducted survival analyses using Kaplan-Meier analysis. RESULTS While no differences in baseline characteristics were identified between the groups, balloon pulmonary angioplasty significantly improved hemodynamics in both groups, without any difference regarding the incidence of complications. Meanwhile, the percent changes in the mean pulmonary arterial pressure, pulmonary vascular resistance, 6-min walk distance, right ventricular area index on echocardiography, and the achievement rate of World Health Organization functional class I after balloon pulmonary angioplasty were significantly lower in Group 1 than in Group 2. The cumulative survival rates at 1, 5, and 10 years after balloon pulmonary angioplasty were not significantly different between the two groups (Group 1: 92.5%, 86.1%, 84.3%; and Group 2: 96.5%, 92.9%, 90.1%, respectively). CONCLUSIONS The outcome of balloon pulmonary angioplasty in inoperable patients with surgically accessible proximal lesions was acceptable; however, further investigations are necessary to clarify the optimal treatment for such patients.
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Affiliation(s)
- Takahiro Nishihara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan; Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 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
| | - Takanori Naito
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Dai Une
- Department of Cardiovascular surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takashi Mukai
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Harutaka Niiya
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
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14
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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15
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Liu Z, Liu X, Lin F, Zheng X, Yang Y, Zhang Y, Fang Y, Ye Z, Liu P, Sun G, Zhen Y. Duration of regional cerebral oxygen saturation under 40% is a risk factor for neurological injury following pulmonary thromboendarterectomy: A prospective observational study. J Card Surg 2022; 37:2610-2617. [PMID: 35599016 DOI: 10.1111/jocs.16615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Zhan Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Fan Lin
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xia Zheng
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yuguang Yang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yajun Zhang
- Department of Surgical Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Yinghui Fang
- Department of Surgical Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
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16
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Forfia P, Ferraro B, Vaidya A. Recognizing Pulmonary Hypertension Following Pulmonary Thromboendarterectomy
A Practical Guide for Clinicians. Pulm Circ 2022; 12:e12073. [DOI: 10.1002/pul2.12073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Bruce Ferraro
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
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17
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Martin-Suarez S, Loforte A, Cavalli GG, Gliozzi G, Botta L, Mariani C, Orioli V, Votano D, Costantino A, Santamaria V, Tassi S, Fiaschini C, Campanini F, Palazzini M, Rossi B, Barbera NA, Niro F, Manes A, Saia F, Dardi F, Galiè N, Pacini D. Therapeutic alternatives in chronic thromboembolic pulmonary hypertension: from pulmonary endarterectomy to balloon pulmonary angioplasty to medical therapy. State of the art from a multidisciplinary team. Ann Cardiothorac Surg 2022; 11:120-127. [PMID: 35433353 PMCID: PMC9012190 DOI: 10.21037/acs-2021-pte-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/02/2022] [Indexed: 08/26/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease with a very complex pathophysiology differing from other causes of pulmonary hypertension (PH). It is an infrequent consequence of acute pulmonary embolism that is frequently misdiagnosed. Pathogenesis has been related to coagulation abnormalities, infection or inflammation, although these disturbances can be absent in many cases. The hallmarks of CTEPH are thrombotic occlusion of pulmonary vessels, variable degree of ventricular dysfunction and secondary microvascular arteriopathy. The definition of CTEPH also includes an increase in mean pulmonary arterial pressure of more than 25 mmHg with a normal pulmonary capillary wedge of less than 15 mmHg. It is classified as World Health Organization group 4 PH, and is the only type that can be surgically cured by pulmonary endarterectomy (PEA). This operation needs to be carried out by a team with strong expertise, from the diagnostic and decisional pathway to the operation itself. However, because the disease has a very heterogeneous phenotype in terms of anatomy, degree of PH and the lack of a standard patient profile, not all cases of CTEPH can be treated by PEA. As a result, PH-directed medical therapy traditionally used for the other types of PH has been proposed and is utilized in CTEPH patients. Since 2015, we have been witnessing the rebirth of balloon pulmonary angioplasty, a technique first performed in 2001 but has since fallen out fashion due to major complications. The refinement of such techniques has allowed its safe utilization as a salvage therapy in inoperable patients. In the present keynote lecture, we will describe these therapeutic approaches and results.
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Affiliation(s)
- Sofia Martin-Suarez
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonio Loforte
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Gregorio Gliozzi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Carlo Mariani
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valentina Orioli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Daniela Votano
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonino Costantino
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valeria Santamaria
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Sara Tassi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Costanza Fiaschini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Campanini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Barbara Rossi
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nicolò Antonino Barbera
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Niro
- Cardiovascular Radiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Dardi
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
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18
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Plácido R, Guimarães T, Jenkins D, Cortez-Dias N, Pereira SC, Campos P, Mineiro A, Lousada N, Martins SR, Moreira S, Dias AR, Resende CL, Vieira R, Pinto FJ. Chronic thromboembolic pulmonary hypertension: Initial experience of patients undergoing pulmonary thromboendarterectomy. Rev Port Cardiol 2021; 40:741-752. [PMID: 34857112 DOI: 10.1016/j.repce.2021.08.002] [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: 08/14/2020] [Accepted: 10/13/2020] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5,2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n=3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.
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Affiliation(s)
- Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal.
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Inglaterra, United Kingdom
| | - Nuno Cortez-Dias
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Sara Couto Pereira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Paula Campos
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Lisboa, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Susana R Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Susana Moreira
- Faculty of Medicine, University of Lisbon, Lisboa, Portugal; Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Rocha Dias
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | | | - Rita Vieira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
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19
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Imtiaz S, Saaedeldin AI, Alqahtani NH, Idrees MM. Clinical and physiological characteristics of, medically treated, chronic thromboembolic pulmonary hypertension patients in Saudi Arabia: A single center experience. Ann Thorac Med 2021; 16:347-353. [PMID: 34820022 PMCID: PMC8588949 DOI: 10.4103/atm.atm_738_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 04/08/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is uncommon but well-known sequel of venous thromboembolism (VTE). At present, it is the only potential curable subtype of pulmonary hypertension. The aim of this study is to describe the medically treated-CTEPH patients' characteristics in a single specialized PH center in Saudi Arabia. METHODS This study presents demographic, clinical, physiological, and hemodynamic characteristics of medically treated-CTEPH patients in a single PH center, namely Prince Sultan Military Medical City, Riyadh, Saudi Arabia. Both incident and prevalent cases are included. RESULTS A total of 20 patients with a confirmed diagnosis of CTEPH were included. Mean age at diagnosis was 43 years with a female preponderance of 75%. Most common presenting symptom was dyspnea (100%) followed by syncope (58%). At diagnosis, a mean of 15 ± 10 months had passed since symptoms onset. About 45% of patients were in WHO functional class IV. At baseline, mean 6-min walk distance was 354.3 meters. Overall, VTE was the most frequent risk factor identified (65% of all patients). Nearly 30% of patients had sickle cell disease. 13 out of 20 patients had radiographic (i.e., computed tomography [CT] pulmonary angiogram) features of chronic thromboembolism. About 75% of patients were found to have distal disease on radiographic imaging. At the time of diagnosis, 7 out of 20 (35%) patients demonstrated right ventricular failure on echocardiography. Mean tricuspid annular plane systolic excursion was 17.7 ± 1.20. Median NT-proBNP levels were found to be 688 pg/ml. Mean diffusing capacity for carbon monoxide was 74.8%. CONCLUSIONS Diagnosis of CTEPH was established at a relatively younger age. Majority of patients had advanced but distal disease on radiographic imaging, not amenable to surgery.
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Affiliation(s)
- Sadia Imtiaz
- Department of Medicine, Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Ahmed I Saaedeldin
- Department of Medicine, Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nayef H Alqahtani
- Department of Radiology, Division of Thoracic Radiology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Majdy M Idrees
- Department of Medicine, Division of Pulmonary Medicine, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
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20
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Ogo T, Shimokawahara H, Kinoshita H, Sakao S, Abe K, Matoba S, Motoki H, Takama N, Ako J, Ikeda Y, Joho S, Maki H, Saeki T, Sugano T, Tsujino I, Yoshioka K, Shiota N, Tanaka S, Yamamoto C, Tanabe N, Tatsumi K. Selexipag for the treatment of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 60:13993003.01694-2021. [PMID: 34824052 PMCID: PMC9260121 DOI: 10.1183/13993003.01694-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 11/04/2021] [Indexed: 11/05/2022]
Abstract
Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin-receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH.In this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary endpoint was the change in pulmonary vascular resistance (PVR) from baseline to week 20. The secondary endpoints were changes in other haemodynamic parameters, 6-min walk distance (6 WMD), Borg Dyspnoea Scale score, World Health Organisation (WHO) functional class, EuroQol 5 dimensions 5-level and N-terminal pro-brain natriuretic peptide.The change in PVR was -98.2±111.3 dyn·s·cm-5 and -4.6±163.6 dyn·s·cm-5 in the selexipag and placebo groups, respectively (mean difference, -93.5 dyn·s·cm-5; 95% confidence interval, -156.8, -30.3; p=0.006). The changes in cardiac index (p<0.001) and Borg Dyspnoea Scale score (p=0.036) were also significantly improved over placebo. 6WMD and WHO functional class were not significantly improved. The common adverse events in the selexipag group were corresponded to those generally observed following a prostacyclin analogue is administered.Selexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.
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Affiliation(s)
- Takeshi Ogo
- Division of Advanced Medical Research in Pulmonary Hypertension, Division of Pulmonary Circulation, Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Centre, Suita, Osaka, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Centre, Okayama, Okayama, Japan
| | - Hideyuki Kinoshita
- Department of Community Medicine Supporting System, Kyoto University Graduate School of Medicine, Kyoto, Kyoto, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kohtaro Abe
- Departments of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences, Fukuoka, Fukuoka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Kyoto, Japan
| | - Hirohiko Motoki
- Department of Cardiology, Shinshu University School of Medicine, Matsumoto, Nagano, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University, Sagamihara, Kanagawa, Japan
| | - Yasuhiro Ikeda
- Department of Cardiology, Yamaguchi Prefectural Grand Medical Centre, Hofu, Yamaguchi, Japan
| | - Shuji Joho
- Second Department of Internal Medicine, University of Toyama, Toyama, Toyama, Japan
| | - Hisataka Maki
- Department of Cardiology, The University of Tokyo Hospital, Tokyo, Tokyo, Japan
| | - Takahiro Saeki
- Cardiovascular Medicine, National Hospital Organization Kanazawa Medical Centre, Kanazawa, Ishikawa, Japan
| | - Teruyasu Sugano
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
| | - Ichizo Tsujino
- Internal Medicine I, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Koichiro Yoshioka
- Department of Cardiology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
| | - Naoki Shiota
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Shinichi Tanaka
- Data Science Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Chieko Yamamoto
- Clinical Development Dept., Nippon Shinyaku Co., Ltd., Kyoto, Kyoto, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan.,Chibaken Saiseikai Narashino Hospital, Narashino, Chiba, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
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21
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Plácido R, Guimarães T, Jenkins D, Cortez-Dias N, Pereira SC, Campos P, Mineiro A, Lousada N, Martins SR, Moreira S, Dias AR, Resende CL, Vieira R, Pinto FJ. Chronic thromboembolic pulmonary hypertension: initial experience of patients undergoing pulmonary thromboendarterectomy. Rev Port Cardiol 2021; 40:S0870-2551(21)00248-1. [PMID: 34474956 DOI: 10.1016/j.repc.2020.10.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5, 2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n = 3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.
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Affiliation(s)
- Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal.
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - David Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, Inglaterra
| | - Nuno Cortez-Dias
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Sara Couto Pereira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Paula Campos
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Lisboa, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Susana R Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal; Faculty of Medicine, University of Lisbon, Lisboa, Portugal
| | - Susana Moreira
- Faculty of Medicine, University of Lisbon, Lisboa, Portugal; Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | - Ana Rocha Dias
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisboa, Portugal
| | | | - Rita Vieira
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon Academic Medical Centre and Cardiovascular Centre, University of Lisbon, Lisboa, Portugal
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22
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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23
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Miura K, Katsumata Y, Kawakami T, Ikura H, Ryuzaki T, Shiraishi Y, Fukui S, Kawakami M, Kohno T, Sato K, Fukuda K. Exercise tolerance and quality of life in hemodynamically partially improved patients with chronic thromboembolic pulmonary hypertension treated with balloon pulmonary angioplasty. PLoS One 2021; 16:e0255180. [PMID: 34297758 PMCID: PMC8301648 DOI: 10.1371/journal.pone.0255180] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/15/2021] [Indexed: 11/18/2022] Open
Abstract
The efficacy of extensive balloon pulmonary angioplasty (BPA) beyond hemodynamic improvement in chronic thromboembolic pulmonary hypertension (CTEPH) patients has been verified. However, the relationship between extensive BPA in CTEPH patients after partial hemodynamic improvement and exercise tolerance or quality of life (QOL) remains unclear. We prospectively enrolled 22 CTEPH patients (66±10 years, females: 59%) when their mean pulmonary artery pressure initially decreased to <30 mmHg during BPA sessions. Hemodynamic and echocardiographic data, cardiopulmonary exercise testing, and QOL scores using the 36-item short form questionnaire (SF-36) were evaluated at enrollment (entry), just after the final BPA session (finish), and at the 6-month follow-up (follow-up). We analyzed whether extensive BPA improves exercise capacity and QOL scores over time. Moreover, the clinical characteristics leading to improvement were elucidated. The peak oxygen uptake (VO2) showed significant improvement at entry, finish, and follow-up (17.3±5.5, 18.4±5.9, and 18.9±5.3 mL/kg/min, respectively; P<0.001). Regarding the QOL, the physical component summary (PCS) scores significantly improved (32±11, 38±13, and 43±13, respectively; P<0.001), but the mental component summary scores remained unchanged. Linear regression analysis revealed that age and a low peak VO2 at entry were predictors of improvement in peak VO2, while low PCS scores and low TAPSE at entry were predictors of improvement in PCS scores. In conclusion, extensive BPA led to improved exercise tolerance and physical QOL scores, even in CTEPH patients with partially improved hemodynamics.
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Affiliation(s)
- Kotaro Miura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Katsumata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
- * E-mail:
| | - Takashi Kawakami
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hidehiko Ikura
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Toshinobu Ryuzaki
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shogo Fukui
- Department of Rehabilitation Medicine, Keio University Hospital, Tokyo, Japan
| | - Michiyuki Kawakami
- Department of Rehabilitation Medicine, Keio University Hospital, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University School of Medicine, Mitaka, Tokyo, Japan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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24
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Cao Y, Geng C, Li Y, Zhang Y. In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease. Front Pharmacol 2021; 12:671589. [PMID: 34305592 PMCID: PMC8296465 DOI: 10.3389/fphar.2021.671589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.
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Affiliation(s)
- Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chao Geng
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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25
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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: advances in patient and lesion selection. Curr Opin Pulm Med 2021; 27:303-310. [PMID: 34224432 DOI: 10.1097/mcp.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Balloon pulmonary angioplasty (BPA) has been performed worldwide for patients who are ineligible for pulmonary endarterectomy (PEA). However, the technical details of BPA have not been standardized, and no international consensus regarding patient and lesion selection for BPA has been reached. Evidence for the combination of BPA with PEA or medical therapy is also lacking. This review highlights recent progress in BPA in terms of patient and lesion selection and the current procedural approach for BPA, including combination treatment. RECENT FINDINGS The indications for BPA have expanded with recent reports describing the improved safety and efficacy of BPA. Because lesions are generally present in all segmental and subsegmental pulmonary arteries, it is recommended to treat all the lesions to achieve desirable hemodynamic improvement. Selective pulmonary angiography is the gold standard for lesion selection in modern BPA aimed at total revascularization. Despite the lack of randomized controlled studies, combination treatment with BPA may be well tolerated and effective. SUMMARY BPA, alone or in combination with PEA or medical therapy, may be a treatment option for patients who are not candidates for monotreatment of PEA. However, further investigation is required to standardize patient and lesion selection for BPA.
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26
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Akay T, Kaymaz C, Rüçhan Akar A, Orhan G, Yanartaş M, Gültekin B, Şırlak M, Kervan Ü, Gezer Taş S, Biçer M, Yağdı T, İspir S, Doğan R. Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension. TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2021; 29:417-431. [PMID: 34589266 PMCID: PMC8462103 DOI: 10.5606/tgkdc.dergisi.2021.21284] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 05/05/2021] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.
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Affiliation(s)
- Tankut Akay
- Department of Cardiovascular Surgery, Başkent University Faculty of Medicine Ankara Hospital, Ankara, Turkey
| | - Cihangir Kaymaz
- Department of Cardiology, University of Health Sciences, Hamidiye Medical Faculty, Koşuyolu Heart Center, Istanbul, Turkey
| | - Ahmet Rüçhan Akar
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gökçen Orhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Mehmed Yanartaş
- Department of Cardiovascular Surgery, Çam ve Sakura Hospital, Istanbul, Turkey
| | - Bahadır Gültekin
- Department of Cardiovascular Surgery, Başkent University Faculty of Medicine Ankara Hospital, Ankara, Turkey
| | - Mustafa Şırlak
- Department of Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ümit Kervan
- Department of Cardiovascular Surgery, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Serpil Gezer Taş
- Department of Cardiovascular Surgery, University of Health Sciences Hamidiye Medical Faculty, Koşuyolu Heart Center, İstanbul, Turkey
| | - Murat Biçer
- Department of Cardiovascular Surgery, Uludağ University Faculty of Medicine, Bursa, Turkey
| | - Tahir Yağdı
- Department of Cardiovascular Surgery, Ege University Faculty of Medicine, Izmir, Turkey
| | - Selim İspir
- Department of Cardiovascular Surgery, Acıbadem University Faculty of Medicine, Istanbul, Turkey
| | - Rıza Doğan
- Department of Cardiovascular Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey
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27
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Colebank MJ, Qureshi MU, Rajagopal S, Krasuski RA, Olufsen MS. A multiscale model of vascular function in chronic thromboembolic pulmonary hypertension. Am J Physiol Heart Circ Physiol 2021; 321:H318-H338. [PMID: 34142886 DOI: 10.1152/ajpheart.00086.2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by recurrent or unresolved pulmonary thromboemboli, leading to perfusion defects and increased arterial wave reflections. CTEPH treatment aims to reduce pulmonary arterial pressure and reestablish adequate lung perfusion, yet patients with distal lesions are inoperable by standard surgical intervention. Instead, these patients undergo balloon pulmonary angioplasty (BPA), a multisession, minimally invasive surgery that disrupts the thromboembolic material within the vessel lumen using a catheter balloon. However, there still lacks an integrative, holistic tool for identifying optimal target lesions for treatment. To address this insufficiency, we simulate CTEPH hemodynamics and BPA therapy using a multiscale fluid dynamics model. The large pulmonary arterial geometry is derived from a computed tomography (CT) image, whereas a fractal tree represents the small vessels. We model ring- and web-like lesions, common in CTEPH, and simulate normotensive conditions and four CTEPH disease scenarios; the latter includes both large artery lesions and vascular remodeling. BPA therapy is simulated by simultaneously reducing lesion severity in three locations. Our predictions mimic severe CTEPH, manifested by an increase in mean proximal pulmonary arterial pressure above 20 mmHg and prominent wave reflections. Both flow and pressure decrease in vessels distal to the lesions and increase in unobstructed vascular regions. We use the main pulmonary artery (MPA) pressure, a wave reflection index, and a measure of flow heterogeneity to select optimal target lesions for BPA. In summary, this study provides a multiscale, image-to-hemodynamics pipeline for BPA therapy planning for patients with inoperable CTEPH. NEW & NOTEWORTHY This article presents novel computational framework for predicting pulmonary hemodynamics in chronic thromboembolic pulmonary hypertension. The mathematical model is used to identify the optimal target lesions for balloon pulmonary angioplasty, combining simulated pulmonary artery pressure, wave intensity analysis, and a new quantitative metric of flow heterogeneity.
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Affiliation(s)
- Mitchel J Colebank
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - M Umar Qureshi
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
| | - Sudarshan Rajagopal
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Richard A Krasuski
- Department of Cardiovascular Medicine, Duke University Health System, Durham, North Carolina
| | - Mette S Olufsen
- Department of Mathematics, North Carolina State University, Raleigh, North Carolina
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28
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Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 249] [Impact Index Per Article: 83.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
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Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
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29
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Kim NH, Papamatheakis DG, Fernandes TM. Evolution of randomized, controlled studies of medical therapy in chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211007373. [PMID: 34104419 PMCID: PMC8150542 DOI: 10.1177/20458940211007373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/09/2021] [Indexed: 12/22/2022] Open
Abstract
Although pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH), many patients have inoperable disease, and some have persistent or recurrent pulmonary hypertension (PH) after surgery. Alternative options (balloon pulmonary angioplasty (BPA) and PH-targeted medical therapy) are, therefore, required. Studies of medical therapies for CTEPH have evolved since Aerosolized Iloprost Randomized (AIR), the first randomized, controlled study of a PH-targeted therapy (inhaled iloprost) to include patients with CTEPH. Key learnings from these studies include the need to evaluate CTEPH separately from other types of PH, the importance of prospective operability adjudication as part of the protocol, and the need for sufficient duration to allow treatment benefits to become apparent. The 16-week Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase-Stimulator Study 1 (CHEST-1) study was the first to operationalize these learnings, demonstrating a significant mean improvement in 6-minute walk distance (+46 m) and improvements in hemodynamic endpoints with riociguat versus placebo. Findings from previous studies will inform the design of future studies to address key issues related to combination medical therapy. Data on combinations of macitentan with phosphodiesterase type 5 inhibitors or oral prostanoids are available from MERIT, the first study to allow such regimens. No data on combinations including riociguat, the only licensed medical therapy for CTEPH, are available. Studies are also needed for multimodality treatment, including medical therapy plus BPA, and medical therapy as a bridge to PEA in selected operable patients. To address these issues and improve patient outcomes, it is vital that we learn from current studies to improve future trial design.
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Affiliation(s)
- Nick H. Kim
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
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30
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Madani MM. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: state-of-the-art 2020. Pulm Circ 2021; 11:20458940211007372. [PMID: 34104418 PMCID: PMC8150486 DOI: 10.1177/20458940211007372] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 01/26/2021] [Indexed: 11/18/2022] Open
Abstract
Pulmonary endarterectomy is the treatment of choice for patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) as it is potentially curative. In expert centers that conduct > 50 pulmonary endarterectomy procedures per year, peri- and post-surgical mortality rates are very low and long-term outcomes are excellent, with three-year post-operative survival of > 80%. Therapeutic decisions in CTEPH are based largely on the location of the arterial obstruction, with pulmonary endarterectomy for obstructions in main, lobar, and segmental vessels, and balloon pulmonary angioplasty and medical therapy for small-vessel disease. Medical therapy is also an option for patients with persistent/recurrent pulmonary hypertension after pulmonary endarterectomy or balloon pulmonary angioplasty. With increasing surgical experience and improvements in instruments and procedures, an increasing number of patients are now considered operable who would previously have been inoperable, including some patients with subsegmental disease. At our University (University of California San Diego), around 200 pulmonary endarterectomy procedures are performed every year and several advances have been developed, including resection of more distal disease, availability of pulmonary endarterectomy to patients previously considered to be at too high risk for surgery, improved management of post-pulmonary endarterectomy complications, and minimally invasive pulmonary endarterectomy. Pulmonary endarterectomy can be combined with other treatment modalities, including balloon pulmonary angioplasty, medical therapy for persistent/recurrent pulmonary hypertension after pulmonary endarterectomy, and medical therapy or balloon pulmonary angioplasty as bridging therapy before surgery. Data on these combinations are, however, limited. Combination treatment should therefore be considered on an individual patient basis. In the future, however, multimodal therapy with pulmonary endarterectomy, balloon pulmonary angioplasty, and/or medical therapy is likely to be an important treatment option for many patients.
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Affiliation(s)
- Michael M. Madani
- Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
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31
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Smolders VFED, Lodder K, Rodríguez C, Tura-Ceide O, Barberà JA, Jukema JW, Quax PHA, Goumans MJ, Kurakula K. The Inflammatory Profile of CTEPH-Derived Endothelial Cells Is a Possible Driver of Disease Progression. Cells 2021; 10:cells10040737. [PMID: 33810533 PMCID: PMC8067175 DOI: 10.3390/cells10040737] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/19/2021] [Accepted: 03/19/2021] [Indexed: 11/30/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension characterized by the presence of fibrotic intraluminal thrombi and causing obliteration of the pulmonary arteries. Although both endothelial cell (EC) dysfunction and inflammation are linked to CTEPH pathogenesis, regulation of the basal inflammatory response of ECs in CTEPH is not fully understood. Therefore, in the present study, we investigated the role of the nuclear factor (NF)-κB pro-inflammatory signaling pathway in ECs in CTEPH under basal conditions. Basal mRNA levels of interleukin (IL)-8, IL-1β, monocyte chemoattractant protein-1 (MCP-1), C-C motif chemokine ligand 5 (CCL5), and vascular cell adhesion molecule-1 (VCAM-1) were upregulated in CTEPH-ECs compared to the control cells. To assess the involvement of NF-κB signaling in basal inflammatory activation, CTEPH-ECs were incubated with the NF-κB inhibitor Bay 11-7085. The increase in pro-inflammatory cytokines was abolished when cells were incubated with the NF-κB inhibitor. To determine if NF-κB was indeed activated, we stained pulmonary endarterectomy (PEA) specimens from CTEPH patients and ECs isolated from PEA specimens for phospho-NF-κB-P65 and found that especially the vessels within the thrombus and CTEPH-ECs are positive for phospho-NF-κB-P65. In summary, we show that CTEPH-ECs have a pro-inflammatory status under basal conditions, and blocking NF-κB signaling reduces the production of inflammatory factors in CTEPH-ECs. Therefore, our results show that the increased basal pro-inflammatory status of CTEPH-ECs is, at least partially, regulated through activation of NF-κB signaling and potentially contributes to the pathophysiology and progression of CTEPH.
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Affiliation(s)
- Valérie F. E. D. Smolders
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (V.F.E.D.S.); (P.H.A.Q.)
- Department of Cell and Chemical Biology, Laboratory for CardioVascular Cell Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (K.L.); (M.J.G.)
| | - Kirsten Lodder
- Department of Cell and Chemical Biology, Laboratory for CardioVascular Cell Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (K.L.); (M.J.G.)
| | - Cristina Rodríguez
- Department of Pulmonary Medicine, Hospital Clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain; (C.R.); (O.T.-C.); (J.A.B.)
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institut (IDIBGI), 17190 Girona, Spain
| | - Olga Tura-Ceide
- Department of Pulmonary Medicine, Hospital Clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain; (C.R.); (O.T.-C.); (J.A.B.)
- Department of Pulmonary Medicine, Dr. Josep Trueta University Hospital de Girona, Santa Caterina Hospital de Salt and the Girona Biomedical Research Institut (IDIBGI), 17190 Girona, Spain
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), 28029 Madrid, Spain
| | - Joan Albert Barberà
- Department of Pulmonary Medicine, Hospital Clínic-Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, 08036 Barcelona, Spain; (C.R.); (O.T.-C.); (J.A.B.)
- Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), 28029 Madrid, Spain
| | - J. Wouter Jukema
- Department of Cardiology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands;
| | - Paul H. A. Quax
- Department of Surgery, Einthoven Laboratory for Experimental Vascular Medicine, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (V.F.E.D.S.); (P.H.A.Q.)
| | - Marie José Goumans
- Department of Cell and Chemical Biology, Laboratory for CardioVascular Cell Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (K.L.); (M.J.G.)
| | - Kondababu Kurakula
- Department of Cell and Chemical Biology, Laboratory for CardioVascular Cell Biology, Leiden University Medical Center, 2300 RC Leiden, The Netherlands; (K.L.); (M.J.G.)
- Correspondence:
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32
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Neutrophil extracellular traps promote fibrous vascular occlusions in chronic thrombosis. Blood 2021; 137:1104-1116. [PMID: 33512471 DOI: 10.1182/blood.2020005861] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 12/09/2020] [Indexed: 02/07/2023] Open
Abstract
Acute pulmonary embolism generally resolves within 6 months. However, if the thrombus is infected, venous thrombi transform into fibrotic vascular obstructions leading to chronic deep vein thrombosis and/or chronic thromboembolic pulmonary hypertension (CTEPH), but precise mechanisms remain unclear. Neutrophils are crucial in sequestering pathogens; therefore, we investigated the role of neutrophil extracellular traps (NETs) in chronic thrombosis. Because chronic pulmonary thrombotic obstructions are biologically identical to chronic deep venous thrombi, the murine inferior vena cava ligation model was used to study the transformation of acute to chronic thrombus. Mice with staphylococcal infection presented with larger thrombi containing more neutrophils and NETs but less resolution. Targeting NETs with DNase1 diminished fibrosis and promoted thrombus resolution. For translational studies in humans, we focused on patients with CTEPH, a severe type of deep venous and pulmonary artery fibrotic obstruction after thrombosis. Neutrophils, markers of neutrophil activation, and NET formation were increased in CTEPH patients. NETs promoted the differentiation of monocytes to activated fibroblasts with the same cellular phenotype as fibroblasts from CTEPH vascular occlusions. RNA sequencing of fibroblasts isolated from thrombo-endarterectomy specimens and pulmonary artery biopsies revealed transforming growth factor-β (TGF-β) as the central regulator, a phenotype which was replicated in mice with fibroblast-specific TGF-β overactivity. Our findings uncover a role of neutrophil-mediated inflammation to enhance TGF-β signaling, which leads to fibrotic thrombus remodeling. Targeting thrombus NETs with DNases may serve as a new therapeutic concept to treat thrombosis and prevent its sequelae.
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33
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Ghofrani HA, D'Armini AM, Kim NH, Mayer E, Simonneau G. Interventional and pharmacological management of chronic thromboembolic pulmonary hypertension. Respir Med 2021; 177:106293. [PMID: 33465538 DOI: 10.1016/j.rmed.2020.106293] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 12/11/2020] [Accepted: 12/27/2020] [Indexed: 11/24/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by obstruction of the pulmonary vasculature, leading to increased pulmonary vascular resistance and ultimately right ventricular failure, the leading cause of death in non-operated patients. This article reviews the current management of CTEPH. The standard of care in CTEPH is pulmonary endarterectomy (PEA). However, up to 40% of patients with CTEPH are ineligible for PEA, and up to 51% develop persistent/recurrent PH after PEA. Riociguat is currently the only medical therapy licensed for treatment of inoperable or persistent/recurrent CTEPH after PEA based on the results of the Phase III CHEST-1 study. Studies of balloon pulmonary angioplasty (BPA) have shown benefits in patients with inoperable or persistent/recurrent CTEPH after PEA; however, data are lacking from large, prospective, controlled studies. Studies of macitentan in patients with inoperable CTEPH and treprostinil in patients with inoperable or persistent/recurrent CTEPH showed positive results. Combination therapy is under evaluation in CTEPH, and long-term data are not available. In the future, CTEPH may be managed by PEA, medical therapy or BPA - alone or in combination, according to individual patient needs. Patients should be referred to experienced centers capable of assessing and delivering all options.
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Affiliation(s)
- Hossein-Ardeschir Ghofrani
- Department of Internal Medicine, University of Giessen and Marburg Lung Center, Giessen, Germany; Department of Pneumology, Kerckhoff-Klinik, Bad Nauheim, Germany; Department of Medicine, Imperial College London, London, UK.
| | - Andrea M D'Armini
- Department of Cardio-Thoracic and Vascular Surgery, Heart and Lung Transplantation and Pulmonary Hypertension Unit, Foundation IRCCS Policlinico San Matteo, University of Pavia School of Medicine, Pavia, Italy
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, University of California, San Diego, USA
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany; Member of the German Center for Lung Research (DZL), Germany
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique, Le Kremlin, Bicêtre, France
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34
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Kenny M, Clarke MM, Pogue KT. Overview of Riociguat and Its Role in the Treatment of Pulmonary Hypertension. J Pharm Pract 2020; 35:437-444. [PMID: 33084500 PMCID: PMC9161433 DOI: 10.1177/0897190020961291] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pulmonary hypertension (PH), which includes pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH), is a progressive condition with significant morbidity and mortality due to right heart failure if left untreated. Riociguat is a soluble guanylate cyclase (sGC) stimulator and is the only treatment approved for both PAH and CTEPH. The objectives of this review are to describe the epidemiology and pathophysiology of PAH and CTEPH; synthesize the pharmacology, efficacy, safety, and utilization of riociguat; and discuss the role of the pharmacist in managing patients with these conditions. Data presented in this review is supported by peer reviewed literature, using PubMed and key words including pulmonary hypertension, pulmonary arterial hypertension, chronic thromboembolic pulmonary hypertension, and riociguat. The review draws on key studies and review articles that discuss the pathophysiology of PAH and CTEPH, as well as articles discussing the safety and efficacy of riociguat. The overall goal in the treatment of PAH and CTEPH is to improve long-term survival. Treatment planning depends on the type of PH, treatment goals, comorbidities, and risk profiles. Pharmacists serve a valuable role as part of the multidisciplinary team in the care of patients with PH, many of whom may have comorbidities that contribute to high costs and resource utilization. Riociguat is a first-in-class medication and the only approved treatment for both PAH and CTEPH. In clinical trials, riociguat has demonstrated favorable efficacy and tolerability. Riociguat is a valuable addition to the armamentarium of options for treating patients with PH.
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Affiliation(s)
| | - Megan M Clarke
- Clinical Pharmacy Specialist, Cardiology, University of North Carolina Medical, Chapel Hill, NC, USA
| | - Kristen T Pogue
- Clinical Pharmacy Specialist, Cardiology, Michigan Medicine, Ann Arbor, MI, USA
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35
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Kondo T, Nakano Y, Adachi S. Potential of Selexipag in Chronic Thromboembolic Pulmonary Hypertension Medical Therapy. Circ J 2020; 84:1691-1692. [DOI: 10.1253/circj.cj-20-0879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Takahisa Kondo
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine
| | - Yoshihisa Nakano
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine
| | - Shiro Adachi
- Department of Cardiology, Nagoya University Hospital
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36
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Tanabe N, Ogo T, Hatano M, Kigawa A, Sunaya T, Sato S. Safety and effectiveness of riociguat for chronic thromboembolic pulmonary hypertension in real-world clinical practice: interim data from post-marketing surveillance in Japan. Pulm Circ 2020; 10:2045894020938986. [PMID: 32754307 PMCID: PMC7378726 DOI: 10.1177/2045894020938986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022] Open
Abstract
This multicenter, prospective, non-interventional study (ClinicalTrials.gov:
NCT02117791) evaluated the safety and effectiveness of riociguat for chronic
thromboembolic pulmonary hypertension in Japanese clinical practice, registering
all patients with chronic thromboembolic pulmonary hypertension treated with
riociguat following its launch in Japan in April 2014. Safety was assessed by
analyzing the adverse drug reactions. Effectiveness measurements included the
assessment of change in World Health Organization functional class, six-minute
walk test, and hemodynamics. Overall, 1031 patients were included in the safety
analysis with 811 (78.7%) patients in World Health Organization functional class
II/III. The mean treatment duration was 591.4 days (median 441.0 days). Adverse
drug reactions were reported in 19.5% of patients, the most common being
hypotension (5.9%), headache (3.0%), dizziness (1.9%), and gastroesophageal
reflux disease (1.5%). Serious adverse drug reactions were reported in 2.1% of
patients. Estimated survival was 97.0% at one year, 95.8% at two years, and
94.4% at three years. The effectiveness analysis (n = 1027)
showed significant increases from baseline in six-minute walking distance, and
significant reductions from baseline in mean pulmonary arterial pressure and
pulmonary vascular resistance. These interim results of riociguat in Japanese
patients with chronic thromboembolic pulmonary hypertension demonstrated a
safety profile that was generally consistent with those of pivotal clinical
studies. The study is ongoing, and will continue to provide insights into the
safety and effectiveness of riociguat in real-world practice.
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Affiliation(s)
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masaru Hatano
- Department of Cardiovascular Medicine, The University of Tokyo, Tokyo, Japan
| | - Ayaka Kigawa
- Medical Affairs Pulmonology and Cardiology, Bayer Yakuhin, Ltd, Osaka, Japan
| | - Toshiyuki Sunaya
- Data Sciences and Analytics, Research and Development Japan, Bayer Yakuhin, Ltd, Osaka, Japan
| | - Shoichiro Sato
- Pharmacovigilance and Medical Governance, Medical Affairs, Bayer Yakuhin, Ltd, Osaka, Japan
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Gurevich S, Prins KW. The evolving role of interventional cardiology in the treatment of pulmonary hypertension. Catheter Cardiovasc Interv 2020; 97:E446-E453. [PMID: 32738190 DOI: 10.1002/ccd.29146] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 07/04/2020] [Indexed: 12/18/2022]
Abstract
Pulmonary hypertension (PH) is a heterogeneous group of diseases defined by a mean pulmonary arterial pressure greater than 20 mmHg. Clinically, PH is classified into five groups and the group of PH generally defines the cause of PH and the therapeutic options. Currently, medical therapies that target the prostacyclin, endothelin, and nitric oxide pathways are used in pulmonary arterial hypertension and chronic thromboembolic PH (CTEPH) patients. Moreover, surgery can improve outcomes in PH as pulmonary thromboendarterectomy can be curative for CTEPH and lung transplantation is used for end-stage PH. Despite these diverse treatment options, PH patients continue to have high symptom burden and poor long-term outcomes. However, advances in percutaneous technology are opening new avenues for the management of PH. In this review, we discuss the available data supporting the use of four interventional procedures: balloon atrial septostomy, transcatheter Potts shunt, balloon pulmonary angioplasty, and pulmonary artery denervation for the treatment of PH. These procedures provide hemodynamic and functional improvements in PH patients, but they come with their own unique risk profiles. Hopefully, these procedures will continue to be refined and thereby provide a venue for interventional cardiology to safely and effectively improve outcomes for PH moving forward.
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Affiliation(s)
- Sergery Gurevich
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
| | - Kurt W Prins
- Cardiovascular Division, University of Minnesota, Minneapolis, Minnesota
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Jin Q, Zhao ZH, Luo Q, Zhao Q, Yan L, Zhang Y, Li X, Yang T, Zeng QX, Xiong CM, Liu ZH. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: State of the art. World J Clin Cases 2020; 8:2679-2702. [PMID: 32742980 PMCID: PMC7360712 DOI: 10.12998/wjcc.v8.i13.2679] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex chronic disease in which pulmonary artery stenosis or obstruction caused by organized thrombus can lead to increased pulmonary artery pressure and pulmonary vascular resistance, ultimately triggering progressive right heart failure and death. Currently, its exact mechanism is not fully understood. Pulmonary endarterectomy (PEA) has immediate effects with low perioperative mortality and satisfactory prognosis in experienced expert centers for CTEPH patients with proximal lesions. Nevertheless, 37% of patients are deemed unsuitable for PEA surgery due to comorbidities and other factors, and nearly half of the operated patients have residual or recurrent pulmonary hypertension. Riociguat is the only approved drug for CTEPH, although its effect is limited. Balloon pulmonary angioplasty (BPA) is a promising alternative treatment for patients with CTEPH. After more than 30 years of development and refinements, emerging evidence has confirmed its role in patients with inoperable CTEPH or residual/recurrent pulmonary hypertension, with acceptable complications and comparable long-term prognosis to PEA. This review summarizes the pathophysiology of CTEPH, BPA history and development, therapeutic principles, indications and contraindications, interventional procedures, imaging modalities, efficacy and prognosis, complications and management, bridging and hybrid therapies, ongoing clinical trials and future prospects.
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Affiliation(s)
- Qi Jin
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qing Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lu Yan
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Zhang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin Li
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qi-Xian Zeng
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
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Sandqvist A, Kylhammar D, Bartfay SE, Hesselstrand R, Hjalmarsson C, Kavianipour M, Nisell M, Rådegran G, Wikström G, Kjellström B, Söderberg S. Risk stratification in chronic thromboembolic pulmonary hypertension predicts survival. SCAND CARDIOVASC J 2020; 55:43-49. [PMID: 32586166 DOI: 10.1080/14017431.2020.1783456] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To investigate if the pulmonary arterial hypertension (PAH) risk assessment tool presented in the 2015 ESC/ERS guidelines is valid for patients with chronic thromboembolic pulmonary hypertension (CTEPH) when taking pulmonary endarterectomy (PEA) into account. Design. Incident CTEPH patients registered in the Swedish PAH Registry (SPAHR) between 2008 and 2016 were included. Risk stratification performed at baseline and follow-up classified the patients as low-, intermediate-, or high-risk using the proposed ESC/ERS risk algorithm. Results. There were 250 CTEPH patients with median age (interquartile range) 70 (14) years, and 53% were male. Thirty-two percent underwent PEA within 5 (6) months. In a multivariable model adjusting for age, sex, and pharmacological treatment, patients with intermediate-risk or high-risk profiles at baseline displayed an increased mortality risk (Hazard Ratio [95% confidence interval]: 1.64 [0.69-3.90] and 5.39 [2.13-13.59], respectively) compared to those with a low-risk profile, whereas PEA was associated with better survival (0.38 [0.18-0.82]). Similar impact of risk profile and PEA was seen at follow-up. Conclusion. The ESC/ERS risk assessment tool identifies CTEPH patients with reduced survival. Furthermore, PEA improves survival markedly independently of risk group and age. Take home message: The ESC/ERS risk stratification for PAH predicts survival also in CTEPH patients, even when taking PEA into account.
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Affiliation(s)
- Anna Sandqvist
- Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden.,Actelion a Division of Janssen-Cilag AB, Stockholm, Sweden
| | - David Kylhammar
- Department of Medical and Health Sciences and department of Clinical Physiology, Linköping University, Linköping, Sweden
| | - Sven-Erik Bartfay
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Roger Hesselstrand
- Department of Clinical Sciences Section of Rheumatology, Lund University, Lund, Sweden
| | - Clara Hjalmarsson
- Department of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden.,Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mohammad Kavianipour
- Department of Public Health and Clinical Medicine, Sundsvall Research Unit, Umeå University, Umeå, Sweden
| | - Magnus Nisell
- Department of Medicine Solna, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden.,The Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Rådegran
- Department of Clinical Sciences Lund, Cardiology, Lund University, Lund, Sweden.,The Section for Heart Failure and Valvular Disease, VO Heart and Lung Medicine, Skåne University Hospital, Lund, Sweden
| | - Gerhard Wikström
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Barbro Kjellström
- Department of Medicine, Cardiology Unit, Karolinska Institute, Stockholm, Sweden.,Department of Clinical Sciences Lund, Clinical Physiology, Lund University, Lund, Sweden.,Skåne University Hospital, Lund, Sweden
| | - Stefan Söderberg
- Department of Public Health and Clinical Medicine, and Heart Centre, Umeå University, Umeå, Sweden
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Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 2020; 55:13993003.00189-2020. [PMID: 32184319 DOI: 10.1183/13993003.00189-2020] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). Untreated CTEPH is fatal, but, if diagnosed in time, successful surgical (pulmonary endarterectomy), medical (pulmonary hypertension drugs) and/or interventional (balloon pulmonary angioplasty) therapies have been shown to improve clinical outcomes, especially in case of successful pulmonary endarterectomy. Early diagnosis has however been demonstrated to be challenging. Poor awareness of the disease by patients and physicians, high prevalence of the post-PE syndrome (i.e. persistent dyspnoea, functional limitations and/or decreased quality of life following an acute PE diagnosis), lack of clear guideline recommendations as well as inefficient application of diagnostic tests in clinical practice lead to a reported staggering diagnostic delay >1 year. Hence, there is a great need to improve current clinical practice and diagnose CTEPH earlier. In this review, we will focus on the clinical presentation of and risk factors for CTEPH, and provide best practices for PE follow-up programmes from expert centres, based on a clinical case.
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Affiliation(s)
- Fredrikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Univ Brest, Brest, France
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals and Respiratory Division, Dept of Chronic Diseases, Metabolism and Aging, KU Leuven - University of Leuven, Leuven, Belgium
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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41
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Aldalaan AM, Saleemi SA, Weheba I, Abdelsayed A, Hämmäinen P, Aleid MM, Alzubi F, Zaytoun H, Alharbi N. Chronic thromboembolic pulmonary hypertension in Saudi Arabia: preliminary results from the SAUDIPH registry. ERJ Open Res 2020; 6:00218-2019. [PMID: 32420315 PMCID: PMC7211951 DOI: 10.1183/23120541.00218-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 02/06/2020] [Indexed: 02/05/2023] Open
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, progressive vascular disease with poor prognosis if left untreated. This study aims to assess the patient characteristics, treatment approach and clinical and survival outcomes for CTEPH patients enrolled in the Systematic Prospective Follow Up for Better Understanding of Clinical Characteristics of Patients with Pulmonary Hypertension Disease (SAUDIPH) registry. Methods This study presents a subanalysis of CTEPH patients enrolled in the SAUDIPH registry. This registry enrolled patients with pulmonary hypertension, established through right heart catheterisation, under clinical management at a specialised tertiary care centre. Patients received standard care during the period of the registry. Results At the time of this analysis, 64 CTEPH patients were enrolled in the registry. Mean age at diagnosis was 39.7 years and there was a female predominance (67.6%). At baseline, most patients were in World Health Organization functional classes III or IV (70.1%). At the last follow-up visit, most patients (63.2%) had undergone endarterectomy, showing significant improvement in disease severity from baseline. Patients who underwent endarterectomy showed numerically higher (p=0.126) probability of survival at 1 year (97.5%) versus those who did not undergo endarterectomy (94.4%). Conclusion Patients were diagnosed at relatively young age, but still showed high disease severity, suggesting delay in diagnosis. Patients who underwent surgical treatment showed substantial improvements in clinical and haemodynamic parameters, while the remaining patients tended to show disease progression. The 96.6% 1-year cumulative probability of survival was high compared to previous studies. The SAUDIPH registry was designed to follow pulmonary hypertension patients in Saudi Arabia. This study assesses patient characteristics and treatment approaches of chronic thromboembolic pulmonary hypertension patients enrolled in the SAUDIPH registry.http://bit.ly/2uCWpBe
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Affiliation(s)
- Abdullah M Aldalaan
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sarfraz A Saleemi
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Ihab Weheba
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Abeer Abdelsayed
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Pekka Hämmäinen
- Organ Transplant Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Maha M Aleid
- Dept of Biostatistics, Epidemiology and Scientific Computing, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fatima Alzubi
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Hamdeia Zaytoun
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Nadeen Alharbi
- Pulmonary Hypertension Program, Dept of Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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42
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Butrous G. Pulmonary hypertension: From an orphan disease to a global epidemic. Glob Cardiol Sci Pract 2020; 2020:e202005. [PMID: 33150150 PMCID: PMC7590934 DOI: 10.21542/gcsp.2020.5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/11/2020] [Indexed: 01/01/2023] Open
Abstract
[No abstract. Showing first paragraph of article]Pulmonary hypertension is a progressive disease characterized by an elevation of pulmonary artery pressure and pulmonary vascular resistance, leading to right ventricular failure and death. It remains a challenging chronic progressive disease, but the current interest and advent of medical therapy in the last 20 years has significantly changed the perception of medical community in this disease. Pulmonary hypertension is not a specific disease; the majority of cases present with other diseases and various pathological processes that affect the pulmonary vasculature, and consequently increase pulmonary pressure and vascular resistance.
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Affiliation(s)
- Ghazwan Butrous
- Medway School of Pharmacy University of Kent at Canterbury, UK
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43
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Gerges M, Yacoub M. Chronic thromboembolic pulmonary hypertension - still evolving. Glob Cardiol Sci Pract 2020; 2020:e202011. [PMID: 33150155 PMCID: PMC7590968 DOI: 10.21542/gcsp.2020.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is one of the leading causes of severe pulmonary hypertension (PH). The disease is still underdiagnosed, and the true prevalence is unknown. CTEPH is characterized by intraluminal non-resolving thrombus organization and fibrous stenosis, or complete obliteration of pulmonary arteries, promoted by progressive remodeling of the pulmonary vasculature. One consequence of this is an increase in pulmonary vascular resistance and pressure, resulting in PH and progressive right heart failure, leading to death if left untreated. Endovascular disobliteration by pulmonary endarterectomy (PEA) is the preferred treatment for CTEPH patients. PEA surgery is the only technique that can potentially cure CTEPH disease, especially in patients with fresh or organized thrombi of the proximal branches of pulmonary arteries. However, not all patients are eligible for PEA surgery. Recent research has provided evidence suggesting balloon pulmonary angioplasty (BPA) and targeted medical therapy as additional promising available treatments options for inoperable CTEPH and recurrent/persistent PH after PEA surgery. Studies on BPA have shown it to improve pulmonary hemodynamics, symptoms, exercise capacity and RV function in inoperable CTEPH. Subsequently, BPA has developed into an essential component of the modern era of CTEPH treatment. Large randomized controlled trials have demonstrated varying significant improvements with targeted medical therapy in technically inoperable CTEPH patients. Thus, treatment of CTEPH requires a comprehensive multidisciplinary assessment, including an experienced PEA surgeon, PH specialist, BPA interventionist and CTEPH-trained radiologist at expert centers. In this comprehensive review, we address the latest developments in the fast-evolving field of CTEPH. These include advancements in imaging modalities and developments in operative and interventional techniques, which have widened the range of patients who may benefit from these procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed. As the treatment options for CTEPH improve, hybrid management involving multiple treatments in the same patient may become a viable option in the near future.
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Affiliation(s)
- Mario Gerges
- Department of Internal Medicine II, Division of Cardiology, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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44
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Kozu K, Satoh K, Aoki T, Tatebe S, Miura M, Yamamoto S, Yaoita N, Suzuki H, Shimizu T, Sato H, Konno R, Terui Y, Nochioka K, Kikuchi N, Satoh T, Sugimura K, Miyata S, Shimokawa H. Cyclophilin A as a biomarker for the therapeutic effect of balloon angioplasty in chronic thromboembolic pulmonary hypertension. J Cardiol 2020; 75:415-423. [DOI: 10.1016/j.jjcc.2019.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/17/2019] [Accepted: 09/18/2019] [Indexed: 12/11/2022]
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Abstract
The treatment of chronic thromboembolic pulmonary hypertension has expanded considerably. The ability to endarterectomize chronic thromboembolic material, the availability of pulmonary hypertension medical therapy to treat inoperable chronic thromboembolic pulmonary hypertension and/or residual pulmonary hypertension, and the rebirth of pulmonary balloon angioplasty have changed the management landscape. Patient selection requires a multidisciplinary evaluation at an experienced center. What is inoperable chronic thromboembolic pulmonary hypertension to one group may be operable chronic thromboembolic pulmonary hypertension to another. The ultimate challenge then becomes which intervention provides the optimal long-term outcome for any individual patient.
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Affiliation(s)
- William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
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46
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Karyofyllis P, Demerouti E, Papadopoulou V, Voudris V, Matsubara H. Balloon Pulmonary Angioplasty as a Treatment in Chronic Thromboembolic Pulmonary Hypertension: Past, Present, and Future. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:7. [DOI: 10.1007/s11936-020-0807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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47
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Savale L, Habibi A, Lionnet F, Maitre B, Cottin V, Jais X, Chaouat A, Artaud-Macari E, Canuet M, Prevot G, Chantalat-Auger C, Montani D, Sitbon O, Galacteros F, Simonneau G, Parent F, Bartolucci P, Humbert M. Clinical phenotypes and outcomes of precapillary pulmonary hypertension of sickle cell disease. Eur Respir J 2019; 54:13993003.00585-2019. [DOI: 10.1183/13993003.00585-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 08/28/2019] [Indexed: 12/18/2022]
Abstract
RationalePrecapillary pulmonary hypertension (PH) is a devastating complication of sickle cell disease (SCD). Little is known about the influence of the SCD genotype on PH characteristics.ObjectivesTo describe clinical phenotypes and outcomes of precapillary PH due to SCD according to disease genotype.MethodsA nationwide multicentre retrospective study including all patients with SCD-related precapillary PH from the French PH Registry was conducted. Clinical characteristics and outcomes according to SCD genotype were analysed.Results58 consecutive SCD patients with precapillary PH were identified, of whom 41 had homozygous for haemoglobin S (SS) SCD, three had S-β0 thalassaemia (S-β0 thal) and 14 had haemoglobin SC disease (SC). Compared to SC patients, SS/S-β0 thal patients were characterised by lower 6-min walk distance (p=0.01) and lower pulmonary vascular resistance (p=0.04). Mismatched segmental perfusion defects on lung scintigraphy were detected in 85% of SC patients and 9% of SS/S-β0 thal patients, respectively, and 50% of SS/S-β0 thal patients had heterogeneous lung perfusion without segmental defects. After PH diagnosis, 31 patients (53%) received medical therapies approved for pulmonary arterial hypertension, and chronic red blood cell exchange was initiated in 23 patients (40%). Four patients were managed for chronic thromboembolic PH by pulmonary endarterectomy (n=1) or balloon pulmonary angioplasty (n=3). Overall survival was 91%, 80% and 60% at 1, 3 and 5 years, respectively, without influence of genotype on prognosis.ConclusionsPatients with precapillary PH related to SCD have a poor prognosis. Thrombotic lesions appear as a major component of PH related to SCD, more frequently in SC patients.
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Zaiou M. Circular RNAs in hypertension: challenges and clinical promise. Hypertens Res 2019; 42:1653-1663. [PMID: 31239534 DOI: 10.1038/s41440-019-0294-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/03/2019] [Accepted: 05/29/2019] [Indexed: 12/14/2022]
Abstract
Hypertension (HT), or high blood pressure (BP), is a chronic disease that is common among populations worldwide. The occurrence of HT is one of the leading causes of cardiovascular morbidity and mortality in adults. Although multiple studies have stressed the multifactorial and multigenic nature of HT, uncertainties about its etiology persist, and current diagnostic biomarkers can explain only a small part of the phenotypic variance of BP. Hence, the search for novel biomarkers that enable early disease prevention and guided therapy is warranted. Regulatory circRNAs have emerged as the newest player in HT-related gene networks and hold promise for improving the accuracy of diagnosis. These RNAs are genome products that are formed through back-splicing of specific regions of pre-mRNAs. Evidence suggests that these RNA species are involved in various metabolic diseases. Recent studies have revealed that aberrant expression of circRNAs is relevant to the occurrence and development of HT. Accordingly, circRNAs are proposed as a new generation of predictive biomarkers and potential therapeutic targets for different forms of HT, including pulmonary hypertension and preeclampsia. This paper presents an overview of the findings from current research focusing on the emerging role of circRNAs in the pathogenesis of hypertension. Furthermore, some of the challenges encountered by circRNA studies are highlighted, and perspectives are provided on the future of research in this area.
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Affiliation(s)
- Mohamed Zaiou
- University of Lorraine, Department of Biochemistry and Molecular Biology, 7 Avenue de la Foret de Haye, BP 90170, 54505, Vandoeuvre les Nancy Cedex, France.
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Humbert M, Farber HW, Ghofrani HA, Benza RL, Busse D, Meier C, Hoeper MM. Risk assessment in pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 53:13993003.02004-2018. [PMID: 30923187 PMCID: PMC6551213 DOI: 10.1183/13993003.02004-2018] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 03/12/2019] [Indexed: 12/21/2022]
Abstract
Background Current pulmonary hypertension treatment guidelines recommend use of a risk stratification model encompassing a range of parameters, allowing patients to be categorised as low, intermediate or high risk. Three abbreviated versions of this risk stratification model were previously evaluated in patients with pulmonary arterial hypertension (PAH) in the French, Swedish and COMPERA registries. Our objective was to investigate the three abbreviated risk stratification methods for patients with mostly prevalent PAH and chronic thromboembolic pulmonary hypertension (CTEPH), in patients from the PATENT-1/2 and CHEST-1/2 studies of riociguat. Methods Risk was assessed at baseline and at follow-up in PATENT-1 and CHEST-1. Survival and clinical worsening-free survival were assessed in patients in each risk group/strata. Results With all three methods, riociguat improved risk group/strata in patients with PAH after 12 weeks. The French non-invasive and Swedish/COMPERA methods discriminated prognosis for survival and clinical worsening-free survival at both baseline and follow-up. Furthermore, patients achieving one or more low-risk criteria or a low-risk stratum at follow-up had a significantly reduced risk of death and clinical worsening compared with patients achieving no low-risk criteria or an intermediate-risk stratum. Similar results were obtained in patients with inoperable or persistent/recurrent CTEPH. Conclusions This analysis confirms and extends the results of the registry analyses, supporting the value of goal-oriented treatment in PAH. Further assessment of these methods in patients with CTEPH is warranted. Riociguat improves risk group in patients with PAH and CTEPH according to three abbreviated versions of the ESC/ERS risk stratification model (results of a post hoc analysis)http://ow.ly/Herk30o8lKM
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Affiliation(s)
- Marc Humbert
- University Paris-Sud, Faculté de Médecine, Université Paris Saclay, Le Kremlin-Bicêtre, France.,AP-HP, Service de Pneumologie, Centre de Référence de l'Hypertension Pulmonaire, Hôpital Bicêtre, Le Kremlin-Bicêtre, France.,INSERM Unité 999, Le Kremlin-Bicêtre, France
| | - Harrison W Farber
- Division of Pulmonary, Critical Care and Sleep Medicine, Tufts Medical Center, Boston, MA, USA
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK
| | - Raymond L Benza
- Cardiovascular Institute, Allegheny General Hospital, Pittsburgh, PA, USA
| | | | | | - Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, Member of the German Center for Lung Research (DZL), Hannover, Germany
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Lipshultz SE, Law YM, Asante-Korang A, Austin ED, Dipchand AI, Everitt MD, Hsu DT, Lin KY, Price JF, Wilkinson JD, Colan SD. Cardiomyopathy in Children: Classification and Diagnosis: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e9-e68. [PMID: 31132865 DOI: 10.1161/cir.0000000000000682] [Citation(s) in RCA: 145] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
In this scientific statement from the American Heart Association, experts in the field of cardiomyopathy (heart muscle disease) in children address 2 issues: the most current understanding of the causes of cardiomyopathy in children and the optimal approaches to diagnosis cardiomyopathy in children. Cardiomyopathies result in some of the worst pediatric cardiology outcomes; nearly 40% of children who present with symptomatic cardiomyopathy undergo a heart transplantation or die within the first 2 years after diagnosis. The percentage of children with cardiomyopathy who underwent a heart transplantation has not declined over the past 10 years, and cardiomyopathy remains the leading cause of transplantation for children >1 year of age. Studies from the National Heart, Lung, and Blood Institute-funded Pediatric Cardiomyopathy Registry have shown that causes are established in very few children with cardiomyopathy, yet genetic causes are likely to be present in most. The incidence of pediatric cardiomyopathy is ≈1 per 100 000 children. This is comparable to the incidence of such childhood cancers as lymphoma, Wilms tumor, and neuroblastoma. However, the published research and scientific conferences focused on pediatric cardiomyopathy are sparcer than for those cancers. The aim of the statement is to focus on the diagnosis and classification of cardiomyopathy. We anticipate that this report will help shape the future research priorities in this set of diseases to achieve earlier diagnosis, improved clinical outcomes, and better quality of life for these children and their families.
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