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Keiler EA, Kerr KM, Poch DS, Yang JZ, Papamatheakis DG, Alotaibi M, Bautista A, Pretorius VG, Madani MM, Kim NH, Fernandes TM. NT-pro-BNP is predictive of morbidity and mortality after pulmonary thromboendarterectomy and is independent of preoperative hemodynamics. Pulm Circ 2024; 14:e12367. [PMID: 38646413 PMCID: PMC11027071 DOI: 10.1002/pul2.12367] [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: 06/25/2023] [Revised: 02/12/2024] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Current predictors of clinical outcomes after pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are largely limited to preoperative clinical characteristics. N-terminal-pro-brain natriuretic peptide (NT-pro-BNP), a biomarker of right ventricular dysfunction, has not yet been well described as one such predictor. From 2017 to 2021, 816 patients with CTEPH referred to the University of California, San Diego for PTE were reviewed for differences in NT-pro-BNP to predict preoperative characteristics and postoperative outcomes up to 30 days post-PTE. For analysis, NT-pro-BNP was dichotomized to less than/equal to or greater than 1000 pg/mL based on the mean of the study population. Mean NT-pro-BNP was 1095.9 ±1783.4 pg/mL and median was 402.5 pg/mL (interquartile range: 119.5-1410.8). Of the 816 patients included, 250 had NT-pro-BNP > 1000 pg/mL. Those with NT-pro-BNP > 1000 pg/mL were significantly more likely to have worse preoperative functional class (III-IV) and worse preoperative hemodynamics. Patients with NT-pro-BNP > 1000 pg/mL also tended to have more postoperative complications including reperfusion pulmonary edema (22% vs. 5.1%, p < 0.001), airway hemorrhage (8.4% vs. 4.9%, p = 0.075), residual pulmonary hypertension (11.9% vs. 3.1%, p < 0.001), and 30-day mortality (4.8% vs. 1.1%, p = 0.001). Even after adjusting for confounders, patients with NT-pro-BNP > 1000 pg/mL had a 2.48 times higher odds (95% confidence interval: 1.45-4.00) of reaching a combined endpoint that included the above complications. Preoperative NT-pro-BNP > 1000 pg/mL is a strong predictor of more severe preoperative hemodynamics and identifies patients at higher risk for postoperative complications.
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Affiliation(s)
- Emanuel A. Keiler
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Kim M. Kerr
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - David S. Poch
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Jenny Z. Yang
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Demosthenes G. Papamatheakis
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Angela Bautista
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Victor G. Pretorius
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Michael M. Madani
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Nick H. Kim
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
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Abbasciano RG, Olivieri GM, Chubsey R, Gatta F, Tyson N, Easwarakumar K, Fudulu DP, Marsico R, Kofler M, Elshafie G, Lai F, Loubani M, Kendall S, Zakkar M, Murphy GJ. Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery. Cochrane Database Syst Rev 2024; 3:CD005566. [PMID: 38506343 PMCID: PMC10952358 DOI: 10.1002/14651858.cd005566.pub4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
BACKGROUND Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.
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Affiliation(s)
| | | | - Rachel Chubsey
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Francesca Gatta
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Nathan Tyson
- Department of Cardiac Surgery, University Hospitals of Leicester, Leicester, UK
| | | | - Daniel P Fudulu
- Department of Cardiac Surgery, University Hospital Bristol NHS Trust, Bristol, UK
| | | | | | - Ghazi Elshafie
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Florence Lai
- Leicester Clinical Trials Unit, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | | | - Mustafa Zakkar
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Gavin J Murphy
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
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Chia AXF, Valchanov K, Ng C, Tsui S, Taghavi J, Vuylsteke A, Fowles JA, Jenkins DP. Perioperative extracorporeal membrane oxygenation support for pulmonary endarterectomy: A 17-year experience from the UK national cohort. J Heart Lung Transplant 2024; 43:241-250. [PMID: 37730188 DOI: 10.1016/j.healun.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 08/30/2023] [Accepted: 09/14/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Pulmonary endarterectomy (PEA) is the guideline-recommended treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients develop severe cardiopulmonary compromise before surgery, intraoperatively, or early postoperatively. This may result from advanced CTEPH, reperfusion pulmonary edema, massive endobronchial bleeding, or right ventricular (RV) failure secondary to residual pulmonary hypertension. Conventional cardiorespiratory support is ineffective when these complications are severe. Since 2005, we used extracorporeal membrane oxygenation (ECMO) as a rescue therapy for this group. We review our experience with ECMO support in these patients. METHODS This study was a retrospective analysis of patients who received perioperative ECMO for PEA from a single national center from August 2005 to July 2022. Data were prospectively collected. RESULTS One hundred and ten patients (4.7%) had extreme cardiorespiratory compromise requiring perioperative ECMO. Nine were established on ECMO before PEA. Of those who received ECMO postoperatively, 39 were for refractory reperfusion lung injury, 20 for RV failure, 31 for endobronchial bleeding, and the remaining 11 were for "other" reasons, such as cardiopulmonary resuscitation following late tamponade and aspiration pneumonitis. Sixty-two (56.4%) were successfully weaned from ECMO. Fifty-seven patients left the hospital alive, giving a salvage rate of 51.8%. Distal disease (Jamieson Type III) and significant residual pulmonary hypertension were also predictors of mortality on ECMO support. Overall, 5- and 10-year survival in patients who were discharged alive following ECMO support was 73.9% (SE: 6.1%) and 58.2% (SE: 9.5%), respectively. CONCLUSIONS Perioperative ECMO support has an appropriate role as rescue therapy for this group. Over 50% survived to hospital discharge. These patients had satisfactory longer-term survival.
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Affiliation(s)
- Alicia X F Chia
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Kamen Valchanov
- Department of Anaesthesia, Singapore General Hospital, Singapore, Singapore
| | - Choo Ng
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Steven Tsui
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - John Taghavi
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Alain Vuylsteke
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - Jo-Anne Fowles
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, United Kingdom.
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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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5
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Astashchanka A, Kerr KM, Yang JZ, Bautista A, Papamatheakis DG, Poch DS, Kim NH, Pretorius VG, Madani MM, Fernandes TM. Repeat pulmonary thromboendarterectomy outcomes: A 15-year single-center retrospective review. J Thorac Cardiovasc Surg 2023; 166:1512-1519.e2. [PMID: 37032250 DOI: 10.1016/j.jtcvs.2023.02.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/24/2023] [Accepted: 02/28/2023] [Indexed: 04/11/2023]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension is potentially curable via pulmonary thromboendarterectomy. A minority of patients experience recurrence of their symptoms and are eligible for repeat pulmonary thromboendarterectomy. However, little data exist regarding risk factors and outcomes for this patient population. METHODS We performed a retrospective review of the University of California San Diego chronic thromboembolic pulmonary hypertension quality improvement database, including all patients who underwent pulmonary thromboendarterectomy from December 2005 to December 2020. Of the 2019 cases performed during this period, 46 were repeat pulmonary thromboendarterectomy procedures. Demographics, preoperative and postoperative hemodynamics, and surgical complications were compared between the repeat pulmonary thromboendarterectomy group and 1008 first pulmonary thromboendarterectomy group. RESULTS Repeat pulmonary thromboendarterectomy recipients were more likely to be younger, to have an identified hypercoagulable state, and to have higher preoperative right atrial pressure. Etiologies of recurrent disease include incomplete initial endarterectomy, discontinuation of anticoagulation (noncompliance or for medical reasons), and anticoagulation treatment failure. Patients who received repeat pulmonary thromboendarterectomy had significant hemodynamic improvement, but less pronounced compared with patients who received first pulmonary thromboendarterectomy. Repeat pulmonary thromboendarterectomy was associated with an increased risk of postoperative bleeding, reperfusion lung injury, residual pulmonary hypertension, and increased ventilator, intensive care unit, and hospital days. However, hospital mortality was similar between the groups (2.2% vs 1.9%). CONCLUSIONS This is the largest reported series of repeat pulmonary thromboendarterectomy surgery. Despite an increase in postoperative complications, this study demonstrates that repeat pulmonary thromboendarterectomy surgery can result in significant hemodynamic improvement with acceptable surgical mortality in an experienced center.
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Affiliation(s)
- Anna Astashchanka
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Kim M Kerr
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Jenny Z Yang
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Angela Bautista
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - David S Poch
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif
| | - Victor G Pretorius
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, Calif
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, Calif
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, Calif.
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Yan S, Gao S, Lou S, Yu C, Sun X, Qian X, Ji B. Does methylprednisolone provide protective effect in total aortic arch replacement requiring hypothermia circulatory arrest and selective cerebral perfusion? Perfusion 2023; 38:1384-1392. [PMID: 35786218 DOI: 10.1177/02676591221113650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Glucocorticoids (GC)were applied in total aortic arch replacement (TAAR) at various dosages in many centers, but with limited evidence. METHODS The retrospective study was aimed to evaluate whether methylprednisolone was associated with better postoperative outcomes in patients undergoing TAAR. Patients undergoing TAAR with moderate hypothermia and selective cerebral perfusion between 2017.1 to 2018.12 in Fuwai hospital were classified into three groups according to doses of methylprednisolone given in the surgery: large-GC group (1500-3000 mg); medium-GC group (500-1000 mg) and no-GC group (0 mg). Postoperative outcomes were compared among three groups. Multivariable analysis was performed to identify the association of methylprednisolone with outcomes. RESULTS Three hundred twenty-eight patients were enrolled. Two hundred twenty-eight were in the large-GC group, 34 were in the medium-GC group, and 66 were in the no-GC group. The incidences of major adverse outcomes in large-GC, medium-GC and no-GC groups were 22.8%, 17.6% and 18.2%, respectively, with no statistical difference. A significant difference was observed in post-cardiopulmonary bypass (CPB) fresh frozen plasma (FFP) transfusion (p < .001) and chest drainage volume (p < .001). Multivariable analysis demonstrated that methylprednisolone was not associated with better outcomes (p = .455), while large doses of methylprednisolone were significantly associated with excessive chest drainage (over 2000 mL) [OR (99% CI) 4.282 (1.66-11.044), p < .001] and excessive post-CPB FFP transfusion (over 400 mL) [OR (99% CI) 2.208 (1.027-4.747), p = .008]. CONCLUSIONS Large doses of methylprednisolone (1500-3000 mg) did not show a protective effect in TAAR with moderate hypothermia arrest plus selective cerebral perfusion and might increase postoperative bleeding and FFP transfusion.
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Affiliation(s)
- Shujie Yan
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xiangyang Qian
- Department of Cardiovascular surgery, State key laboratory of Cardiovascular Medicine, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, State key laboratory of Cardiovascular Medicine, Fuwai Hospital, National center for Cardiovascular disease, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
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Ma J, Li C, Zhai Z, Zhen Y, Wang D, Liu M, Liu X, Duan J. Distribution of thrombus predicts severe reperfusion pulmonary edema after pulmonary endarterectomy. Asian J Surg 2023; 46:3766-3772. [PMID: 36997419 DOI: 10.1016/j.asjsur.2023.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/28/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVES Patients underwent pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to investigate the effect of thrombus distribution on the occurrence of severe reperfusion pulmonary edema (RPE) and identify specific parameters for predicting severe RPE. METHODS Patients with CTEPH who underwent PEA surgery were retrospectively analyzed. The thrombus in pulmonary arteries were evaluated through computed tomography pulmonary angiography. Based on presence of prolonged artificial ventilation, extracorporeal membrane oxygenation required, or perioperative death due to RPE, the patients were divided into the severe RPE and without severe RPE groups. MAIN RESULTS Among the 77 patients (29 women), 16 (20.8%) patients developed severe RPE. The right major pulmonary artery (RPA) (0.64[0.58, 0.73] vs 0.58[0.49, 0.64]; p = 0.008) and pulmonary artery trunk (PAT) thrombus ratios (0.48[0.44, 0.61] vs 0.42[0.39, 0.50]; p = 0.009) (the PAT ratio is expressed as the sum of the right middle lobe clot burden and right lower lobe clot burden divided by the total clot burden multiplied by 100) of the severe RPE group was significantly higher than that of the without severe RPE group. Receiver operator characteristics curve identified a PAT ratio of 43.4% as the threshold with areas under the curve = 0.71(95%CI 0.582; 0.841) for the development of severe RPE (sensitivity 0.875, specificity 0.541). The logistic regression analysis demonstrated that age, period from symptom onset to PEA, NT-pro BNP, preoperative mPAP, preoperative PVR, RPA ratio, and PAT ratio were associated with the development of severe RPE. Multivariable logistic regression analysis revealed PAT ratio (odds ratio = 10.2; 95% confidence interval 1.87, 55.53, P = 0.007) and period from symptom onset to PEA (OR = 1.01; 95% CI = 1.00-1.02, P = 0.015) as independent risk factors for the development of severe RPE. CONCLUSIONS The thrombus distribution could be a key factor in the severity of RPE. PAT ratio and medical history could predict the development of severe RPE.
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Affiliation(s)
- Junyu Ma
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Chen Li
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Dingyi Wang
- Department of Clinical research and Data management, Center of Respiratory Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Jun Duan
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China.
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Parvizi R, Bilehjani E, Mahmoudian B, Koohi A, Shojaan H, Ansarin K, Rashidi F. Single-Center Experience of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: The Results from the Tabriz University Medical Sciences (TUMS) CTEPH Program. Thorac Cardiovasc Surg 2023; 71:407-412. [PMID: 36657456 DOI: 10.1055/s-0042-1760204] [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: 01/21/2023]
Abstract
INTRODUCTION Pulmonary endarterectomy (PEA) remains the preferred and potentially curative option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to report the results of PEA for CTEPH in a tertiary center in Tabriz, Iran. METHODS We analyzed the results of 42 CTEPH patients undergoing PEA, who were enrolled in the Tabriz University of Medical Sciences (TUMS-CTEPH) from January 2016 to October 2020. The main outcome measures included the New York Heart Association (NYHA) functional classification, the 6-Minute Walk Distance, hemodynamic measures in right heart catheterization, morbidity, and mortality. RESULTS There was a significant improvement in the NYHA function class (2.6 ± 0.5 vs 1.1 ± 0.34), mean pulmonary arterial pressure (47.1 ± 13 vs 27.9 ± 8 mm Hg), cardiac output (4.3 ± 1.06 vs 5.9 ± 1.2 L/min), and pulmonary vascular resistance (709.4 ± 297.5 vs 214 ± 77 dyn s/cm5). Fifteen patients (35%) developed complications. The most common complication (10 [23%]) was reperfusion injury. Also, postsurgical mortality was 4% during hospital admission and 1-year follow-up. CONCLUSION This is the first single-center report of PEA from Iran. Post-PEA and 1-year survival were acceptable as a referral center. PEA can be performed safe with low mortality. Greater awareness of PEA and patients' access to experienced CTEPH centers are important issues.
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Affiliation(s)
- Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Eisa Bilehjani
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Mahmoudian
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hooriah Shojaan
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Khalil Ansarin
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Farid Rashidi
- Tuberculosis and Lung Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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9
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Simonneau G, Fadel E, Vonk Noordegraaf A, Toshner M, Lang IM, Klok FA, McInnis MC, Screaton N, Madani MM, Martinez G, Salaunkey K, Jenkins DP, Matsubara H, Brénot P, Hoeper MM, Ghofrani HA, Jaïs X, Wiedenroth CB, Guth S, Kim NH, Pepke-Zaba J, Delcroix M, Mayer E. Highlights from the International Chronic Thromboembolic Pulmonary Hypertension Congress 2021. Eur Respir Rev 2023; 32:32/167/220132. [PMID: 36754432 PMCID: PMC9910339 DOI: 10.1183/16000617.0132-2022] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 10/14/2022] [Indexed: 02/10/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. It is caused by persistent obstruction of pulmonary arteries by chronic organised fibrotic clots, despite adequate anticoagulation. The pulmonary hypertension is also caused by concomitant microvasculopathy which may progress without timely treatment. Timely and accurate diagnosis requires the combination of imaging and haemodynamic assessment. Optimal therapy should be individualised to each case and determined by an experienced multidisciplinary CTEPH team with the ability to offer all current treatment modalities. This report summarises current knowledge and presents key messages from the International CTEPH Conference, Bad Nauheim, Germany, 2021. Sessions were dedicated to 1) disease definition; 2) pathophysiology, including the impact of the hypertrophied bronchial circulation, right ventricle (dys)function, genetics and inflammation; 3) diagnosis, early after acute pulmonary embolism, using computed tomography and perfusion techniques, and supporting the selection of appropriate therapies; 4) surgical treatment, pulmonary endarterectomy for proximal and distal disease, and peri-operative management; 5) percutaneous approach or balloon pulmonary angioplasty, techniques and complications; and 6) medical treatment, including anticoagulation and pulmonary hypertension drugs, and in combination with interventional treatments. Chronic thromboembolic pulmonary disease without pulmonary hypertension is also discussed in terms of its diagnostic and therapeutic aspects.
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Affiliation(s)
- Gérald Simonneau
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | - Elie Fadel
- Research and Innovation Unit, INSERM UMR-S 999, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Department of Thoracic and Vascular Surgery and Heart-Lung Transplantation, Marie Lannelongue Hospital, Université Paris-Sud, Université Paris-Saclay, Le Plessis-Robinson, France,Université Paris-Sud and Université Paris-Saclay, School of Medicine, Kremlin-Bicêtre, France
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Mark Toshner
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | - Irene M. Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Micheal C. McInnis
- Department of Medical Imaging, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Michael M. Madani
- Cardiovascular and Thoracic Surgery, University of California-San Diego, La Jolla, CA, USA
| | | | - Kiran Salaunkey
- Royal Papworth Hospital, University of Cambridge, Cambridge, UK
| | | | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Philippe Brénot
- Department of Radiology, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Marius M. Hoeper
- Department of Respiratory Medicine, Hannover Medical School and Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Hossein A. Ghofrani
- Pulmonary Vascular Research, Justus-Liebig University and Pulmonary Hypertension Division, University Hospital Giessen, Giessen, Germany,Department of Pneumology, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Xavier Jaïs
- AP-HP, Service de Pneumologie, Hôpital Bicêtre, Université Paris-Sud, Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999, Le Kremlin-Bicêtre, France
| | | | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Nick H. Kim
- Division of Pulmonary and Critical Care Medicine, University of California-San Diego, La Jolla, CA, USA
| | | | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium .,M. Delcroix and E. Mayer equal contribution (co-last authors)
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany,Meeting organiser,M. Delcroix and E. Mayer equal contribution (co-last authors)
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10
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Inhibition of JAK1,2 Prevents Fibrotic Remodeling of Pulmonary Vascular Bed and Improves Outcomes in the Rat Model of Chronic Thromboembolic Pulmonary Hypertension. Int J Mol Sci 2022; 23:ijms232415646. [PMID: 36555286 PMCID: PMC9779027 DOI: 10.3390/ijms232415646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/15/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism with poor clinical outcomes. Therapeutic approaches to prevention of fibrotic remodeling of the pulmonary vascular bed in CTEPH are limited. In this work, we tested the hypothesis that Janus kinase 1/2 (JAK1/2) inhibition with ruxolitinib might prevent and attenuate CTEPH in a rat model. CTEPH was induced by repeated embolization of the pulmonary artery with partially biodegradable 180 ± 30 μm alginate microspheres. Two weeks after the last injection of microspheres, ruxolitinib was administered orally at doses of 0.86, 2.58, and 4.28 mg/kg per day for 4 weeks. Prednisolone (1.475 mg/kg, i.m.) was used as a reference drug. Ruxolitinib in all doses as well as prednisolone reduced pulmonary vascular wall hypertrophy. Ruxolitinib at a dose of 2.58 mg/kg and prednisolone reduced vascular wall fibrosis. Prednisolone treatment resulted in decreased right ventricular systolic pressure. Pulmonary vascular resistance was lower in the prednisolone and ruxolitinib (4.28 mg/kg) groups in comparison with the placebo group. The plasma level of brain natriuretic peptide was lower in groups receiving ruxolitinib at doses of 2.58 and 4.28 mg/kg versus placebo. This study demonstrated that JAK1/2 inhibitor ruxolitinib dose-dependently reduced pulmonary vascular remodeling, thereby preventing CTEPH formation in rats.
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11
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Rodgers M, Kirkby L, Amaral‐Almeida L, Sheares K, Toshner M, Taboada D, Ng C, Cannon J, D'Errico L, Ruggiero A, Screaton N, Jenkins D, Coghlan J, Pepke‐Zaba J, Hoole SP. Acute lung injury after balloon pulmonary angioplasty results in a similar haemodynamic response and possible clinical advantage at follow-up. Pulm Circ 2022; 12:e12166. [PMID: 36568689 PMCID: PMC9768413 DOI: 10.1002/pul2.12166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/26/2022] [Accepted: 11/24/2022] [Indexed: 11/30/2022] Open
Abstract
Acute lung injury (ALI) is a common but poorly defined and understood complication of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Little data are available on the medium term clinical outcomes of BPA complicated by ALI. We analyzed per-procedure data from 282 procedures in 109 patients and per-patient data from 85 patients. Serial right heart catheterization at baseline, after each BPA and at 3-month follow-up measured pulmonary vascular resistance (PVR), mean pulmonary artery pressure (mPAP), and cardiac output (CO). ALI (ALI+) was identified by chest radiography alone (ALIr+) or in association with hypoxia clinically (ALIcr+). Procedural predictors of ALI and patient outcomes at 3-months were compared no ALI (ALI-). ALI+ occurred in 17/282 (6.0%) procedures (ALIcr+: 2.5%, ALIr+: 3.5%). Prevailing haemodynamics (PVR: p < 0.01; mPAP: p < 0.05) at a procedural and patient level, as well as number of BPA sessions (p < 0.01), total number of vessels (p < 0.05), and occlusions (p < 0.05) treated at a patient level predicted ALI+. Those with ALI had greater percentage improvement in ΔCAMPHOR symptoms score (ALI+: -63.5 ± 35.7% (p < 0.05); ALIcr+: -84.4 ± 14.5% (p < 0.01); ALI-: -27.2 ± 74.2%) and ΔNT-proBNP (ALIcr+: -78.4 ± 11.9% (p < 0.01); ALI-: -42.9 ± 36.0%) at follow-up. There was no net significant difference in haemodynamic changes in ALI+ versus ALI- at follow-up. ALI is predicted by haemodynamic severity, number of vessels treated, number of BPA sessions, and treating occlusive disease. ALI in this cohort was associated with a clinical advantage at follow-up.
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Affiliation(s)
| | | | | | - Karen Sheares
- Pulmonary Vascular Disease UnitRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - Mark Toshner
- Department of MedicineUniversity of CambridgeCambridgeUK
- Pulmonary Vascular Disease UnitRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - Dolores Taboada
- Pulmonary Vascular Disease UnitRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - Choo Ng
- Department of Cardiothoracic SurgeryRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - John E. Cannon
- Pulmonary Vascular Disease UnitRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | | | | | | | - David Jenkins
- Department of Cardiothoracic SurgeryRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - John G. Coghlan
- Department of Interventional CardiologyRoyal Free HospitalLondonUK
| | - Joanna Pepke‐Zaba
- Pulmonary Vascular Disease UnitRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
| | - Stephen P. Hoole
- Department of Interventional CardiologyRoyal Papworth Hospital NHS Foundation TrustCambridgeUK
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12
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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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13
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Surgical Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2022; 40:89-101. [PMID: 34809920 PMCID: PMC8720361 DOI: 10.1016/j.ccl.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive disease, which may lead to severe right ventricular dysfunction and debilitating symptoms. Pulmonary thromboendarterectomy (PTE) provides the best opportunity for complete resolution of obstructing thromboembolic disease and functional improvement in appropriately selected patients. In this article, the authors review preoperative workup, patient selection, operative technique, postoperative care, and outcomes after PTE.
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14
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Mangukia C, Rali P, Desai P, Ku TSJ, Brann S, Patel S, Sunagawa G, Minakata K, Kehara H, Toyoda Y. Pulmonary endarterectomy. Indian J Thorac Cardiovasc Surg 2021; 37:662-672. [PMID: 34776663 PMCID: PMC8545999 DOI: 10.1007/s12055-021-01208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension is an underdiagnosed condition. Patients typically present with the symptoms of right heart failure. Diagnosis is usually done by radionuclide ventilation/perfusion (VQ) scan, high-quality multidetector computed tomography (CT) or pulmonary angiography at expert centers. Pulmonary endarterectomy remains the corner stone in management of chronic thromboembolic pulmonary hypertension. Deep hypothermic circulatory arrest is commonly used for the operation at most centers. In-hospital mortality ranges from 1.7 to 14.2%. Pulmonary hemorrhage, reperfusion lung injury, and right ventricular failure remain major early post-operative concerns. Five-year survival is reported to be 76 to 89%. Long-term outcome depends on residual pulmonary hypertension. Balloon pulmonary angioplasty and medical management play an adjunctive role. Here, we provide a comprehensive review on surgical management of chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Chirantan Mangukia
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Tse-Shuen Jade Ku
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Stacey Brann
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Shrey Patel
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Gengo Sunagawa
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Kenji Minakata
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Hiromu Kehara
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
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15
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Wang LF, Sun YY, Pan Q, Yin YQ, Tian XM, Liu Y, Bu T, Zhang Q, Wang YA, Zhao J, Luo Y. Diminazen Aceturate Protects Pulmonary Ischemia-Reperfusion Injury via Inhibition of ADAM17-Mediated Angiotensin-Converting Enzyme 2 Shedding. Front Pharmacol 2021; 12:713632. [PMID: 34712133 PMCID: PMC8546118 DOI: 10.3389/fphar.2021.713632] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 09/16/2021] [Indexed: 01/30/2023] Open
Abstract
Lung ischemia-reperfusion (IR) injury is induced by pulmonary artery occlusion and reperfusion. Lung IR injury commonly happens after weaning from extracorporeal circulation, lung transplantation, and pulmonary thromboendarterectomy; it is a lethal perioperative complication. A definite therapeutic intervention remains to be determined. It is known that the enzyme activity of angiotensin-converting enzyme 2 (ACE2) is critical in maintaining pulmonary vascular tone and epithelial integrity. In a noxious environment to the lungs, inactivation of ACE2 is mainly due to a disintegrin and metalloprotease 17 (ADAM17) protein-mediated ACE2 shedding. Thus, we assumed that protection of local ACE2 in the lung against ADAM17-mediated shedding would be a therapeutic target for lung IR injury. In this study, we established both in vivo and in vitro models to demonstrate that the damage degree of lung IR injury depends on the loss of ACE2 and ACE2 enzyme dysfunction in lung tissue. Treatment with ACE2 protectant diminazen aceturate (DIZE) maintained higher ACE2 enzyme activity and reduced angiotensin II, angiotensin type 1 receptor, and ADAM17 levels in the lung tissue. Concurrently, DIZE-inhibited oxidative stress and nitrosative stress via p38MAPK and NF-κB pathways consequently reduced release of pro-inflammatory cytokines such as TNF-α, IL-6, and IL-1β. The underlying molecular mechanism of DIZE contributed to its protective effect against lung IR injury and resulted in the improvement of oxygenation index and ameliorating pulmonary pathological damage. We concluded that DIZE protects the lungs from IR injury via inhibition of ADAM17-mediated ACE2 shedding.
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Affiliation(s)
| | - Yang-Yang Sun
- Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences (AMMS), Beijing, China
| | - Qian Pan
- China-Japan Friendship Hospital, Beijing, China
| | - Yi-Qing Yin
- China-Japan Friendship Hospital, Beijing, China
| | | | - Yue Liu
- China-Japan Friendship Hospital, Beijing, China
| | - Tegeleqi Bu
- China-Japan Friendship Hospital, Beijing, China
| | - Qingy Zhang
- China-Japan Friendship Hospital, Beijing, China
| | - Yong-An Wang
- Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences (AMMS), Beijing, China
| | - Jing Zhao
- China-Japan Friendship Hospital, Beijing, China
| | - Yuan Luo
- Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences (AMMS), Beijing, China
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16
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Kaskinen AK, Keski-Nisula J, Martelius L, Moilanen E, Hämäläinen M, Rautiainen P, Andersson S, Pitkänen-Argillander OM. Lung Injury After Neonatal Congenital Cardiac Surgery Is Mild and Modifiable by Corticosteroids. J Cardiothorac Vasc Anesth 2021; 35:2100-2107. [PMID: 33573926 DOI: 10.1053/j.jvca.2021.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 01/04/2021] [Accepted: 01/11/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The present study was performed to determine whether lung injury manifests as lung edema in neonates after congenital cardiac surgery and whether a stress-dose corticosteroid (SDC) regimen attenuates postoperative lung injury in neonates after congenital cardiac surgery. DESIGN A supplementary report of a randomized, double-blinded, placebo-controlled clinical trial. SETTING A pediatric tertiary university hospital. PARTICIPANTS Forty neonates (age ≤28 days) undergoing congenital cardiac surgery with cardiopulmonary bypass. INTERVENTIONS After anesthesia induction, patients were assigned randomly to receive intravenously either 2 mg/kg methylprednisolone or placebo b, which was followed by hydrocortisone or placebo bolus six hours after weaning from CPB for five days as follows: 0.2 mg/kg/h for 48 hours, 0.1 mg/kg/h for the next 48 hours, and 0.05 mg/kg/h for the following 24 hours. MEASUREMENTS AND MAIN RESULTS The chest radiography lung edema score was lower in the SDC than in the placebo group on the first postoperative day (POD one) (p = 0.03) and on PODs two and three (p = 0.03). Furthermore, a modest increase in the edema score of 0.9 was noted in the placebo group, whereas the edema score remained at the preoperative level in the SDC group. Postoperative dynamic respiratory system compliance was higher in the SDC group until POD three (p < 0.01). However, postoperative oxygenation; length of mechanical ventilation; and tracheal aspirate biomarkers of inflammation and oxidative stress, namely interleukin-6, interleukin-8, resistin, and 8-isoprostane, showed no differences between the groups. CONCLUSIONS The SDC regimen reduced the development of mild and likely clinically insignificant radiographic lung edema and improved postoperative dynamic respiratory system compliance without adverse events, but it failed to improve postoperative oxygenation and length of mechanical ventilation.
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Affiliation(s)
- Anu K Kaskinen
- Division of Pediatric Nephrology and Transplantation, Children's Hospital and Pediatric Research Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Juho Keski-Nisula
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Laura Martelius
- Department of Radiology, HUS Medical Imaging Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eeva Moilanen
- The Immunopharmacology Research Group, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Mari Hämäläinen
- The Immunopharmacology Research Group, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | - Paula Rautiainen
- Department of Anesthesia and Intensive Care, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sture Andersson
- Children's Hospital and Pediatric Research Center, Helsinki University Hospital and Helsinki University, Helsinki, Finland
| | - Olli M Pitkänen-Argillander
- Division of Pediatric Cardiology, Children's Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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17
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Ikubo Y, Sanada TJ, Tanabe N, Naito A, Shoji H, Nagata J, Kuriyama A, Yanagisawa A, Kobayashi T, Yamamoto K, Kasai H, Suda R, Sekine A, Sugiura T, Shigeta A, Ishida K, Sakao S, Masuda M, Tatsumi K. The extent of enlarged bronchial arteries is not correlated with the development of reperfusion pulmonary edema after pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension. Pulm Circ 2020; 10:2045894020968677. [PMID: 33282195 PMCID: PMC7682219 DOI: 10.1177/2045894020968677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/03/2020] [Indexed: 11/16/2022] Open
Abstract
This study investigated whether dilated bronchial arteries are associated with reperfusion pulmonary edema in patients with chronic thromboembolic pulmonary hypertension. Results showed that the extent of enlarged bronchial arteries was not associated with the development of reperfusion pulmonary edema, whereas the residual pulmonary hypertension had a significant association.
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Affiliation(s)
- Yumiko Ikubo
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Takayuki J Sanada
- Department of Respirology, Graduate School of Medicine, Chiba, Japan.,Department of Pulmonology, Vrije Universiteit, Amsterdam, the Netherlands
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, Japan
| | - Akira Naito
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Hiroki Shoji
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Jun Nagata
- Department of Respirology, Graduate School of Medicine, Chiba, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, Japan
| | - Ayaka Kuriyama
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Asako Yanagisawa
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | | | - Keiko Yamamoto
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Rika Suda
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Ayumi Sekine
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of Medicine, Chiba, Japan.,Department of Respirology, Chibaken Saiseikai Narashino Hospital, Narashino, Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Chiba University, Chiba, Japan.,Department of Cardiovascular Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba University, Chiba, Japan.,Department of Cardiovascular Surgery, Eastern Chiba Medical Center, Togane, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba, Japan
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18
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Ng KT, Van Paassen J, Langan C, Sarode DP, Arbous MS, Alston RP, Dekkers OM. The efficacy and safety of prophylactic corticosteroids for the prevention of adverse outcomes in patients undergoing heart surgery using cardiopulmonary bypass: a systematic review and meta-analysis of randomized controlled trials. Eur J Cardiothorac Surg 2020; 57:620-627. [DOI: 10.1093/ejcts/ezz325] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/12/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Abstract
Corticosteroids are often administered prophylactically to attenuate the inflammatory response associated with cardiac surgery using cardiopulmonary bypass (CPB). However, the efficacy and safety profile of corticosteroids remain uncertain. The primary aim of this systematic review and meta-analysis was to investigate the effect of corticosteroids on mortality in adult cardiac surgery using CPB. Secondary aims were to examine the effect of corticosteroids on myocardial adverse events, pulmonary adverse events, atrial fibrillation, surgical site infection, gastrointestinal bleeding and duration of stay in the intensive care unit and hospital. Randomized controlled trials (RCTs) were systematically searched in electronic databases (MEDLINE, EMBASE, CINAHL, CENTRAL and Web of Science) from their inception until March 2019. Observational studies, case reports, case series and literature reviews were excluded. Sixty-two studies (n = 16 457 patients) were included in this meta-analysis. There was no significant difference in mortality between the corticosteroid and placebo groups [odds ratio (OR) 0.96, 95% confidence interval (CI) 0.81–1.14; P = 0.65, participants = 14 693, studies = 24, evidence of certainty: moderate]. Compared to those receiving a placebo, patients who were given corticosteroids had a significantly higher incidence of myocardial adverse events (OR 1.17, 95% CI 1.03–1.33; P = 0.01, participants = 14 512, studies = 23) and a lower incidence of pulmonary adverse events (OR 0.86, 95% CI 0.75–0.98; P = 0.02, participants = 13 426, studies = 17). The incidences of atrial fibrillation (OR 0.87, 95% CI 0.81–0.94; P < 0.001, participants = 14 148, studies = 24) and surgical site infection (OR 0.81, 95% CI 0.73–0.90; P < 0.001, participants = 13 946; studies = 22) were all lower in patients who were given corticosteroids. In the present meta-analysis of 62 RCTs (16 457 patients), including the 2 major RCTs (SIRS and DECS trials: 12 001 patients), we found that prophylactic corticosteroids in cardiac surgery did not reduce mortality. The clinical significance of an increase in myocardial adverse events remains unclear as the definition of a relevant myocardial end point following cardiac surgery varied greatly between RCTs.
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Affiliation(s)
- Ka Ting Ng
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Judith Van Paassen
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Clare Langan
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - Deep Pramod Sarode
- Department of General Surgery, NHS Greater Glasgow & Clyde, Scotland, UK
| | - M Sesmu Arbous
- Department of Intensive Care, Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - R Peter Alston
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
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19
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Anderson MR, Udupa JK, Edwin E, Diamond JM, Singer JP, Kukreja J, Hays SR, Greenland JR, Ferrante A, Lippel M, Blue T, McBurnie A, Oyster M, Kalman L, Rushefski M, Wu C, Pednekar G, Liu W, Arcasoy S, Sonett J, D'Ovidio F, Bacchetta M, Newell JD, Torigian D, Cantu E, Farber DL, Giles JT, Tong Y, Palmer S, Ware LB, Hancock WW, Christie JD, Lederer DJ. Adipose tissue quantification and primary graft dysfunction after lung transplantation: The Lung Transplant Body Composition study. J Heart Lung Transplant 2019; 38:1246-1256. [PMID: 31474492 PMCID: PMC6883162 DOI: 10.1016/j.healun.2019.08.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 07/30/2019] [Accepted: 08/05/2019] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Obesity is associated with an increased risk of primary graft dysfunction (PGD) after lung transplantation. The contribution of specific adipose tissue depots is unknown. METHODS We performed a prospective cohort study of adult lung transplant recipients at 4 U.S. transplant centers. We measured cross-sectional areas of subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT) on chest and abdominal computed tomography (CT) scans and indexed each measurement to height.2 We used logistic regression to examine the associations of adipose indices and adipose classes with grade 3 PGD at 48 or 72 hours, and Cox proportional hazards models to examine survival. We used latent class analyses to identify the patterns of adipose distribution. We examined the associations of adipose indices with plasma biomarkers of obesity and PGD. RESULTS A total of 262 and 117 subjects had available chest CT scans and underwent protocol abdominal CT scans, respectively. In the adjusted models, a greater abdominal SAT index was associated with an increased risk of PGD (odds ratio 1.9, 95% CI 1.02-3.4, p = 0.04) but not with survival time. VAT indices were not associated with PGD risk or survival time. A greater abdominal SAT index correlated with greater pre- and post-transplant leptin (r = 0.61, p < 0.001, and r = 0.44, p < 0.001), pre-transplant IL-1RA (r = 0.25, p = 0.04), and post-transplant ICAM-1 (r = 0.25, p = 0.04). We identified 3 latent patterns of adiposity. The class defined by high thoracic and abdominal SAT had the greatest risk of PGD. CONCLUSIONS Subcutaneous, but not visceral, adiposity is associated with an increased risk of PGD after lung transplantation.
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Affiliation(s)
- Michaela R Anderson
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Jayaram K Udupa
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ethan Edwin
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Joshua M Diamond
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jonathan P Singer
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Jasleen Kukreja
- Department of Surgery, University of California at San Francisco, San Francisco, California
| | - Steven R Hays
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - John R Greenland
- Department of Medicine University of California at San Francisco, San Francisco, California
| | - Anthony Ferrante
- Columbia Institute of Human Nutrition, Columbia University Medical Center, New York, New York
| | - Matthew Lippel
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Tatiana Blue
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Amika McBurnie
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Michelle Oyster
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurel Kalman
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Rushefski
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caiyun Wu
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gargi Pednekar
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wen Liu
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Joshua Sonett
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Matthew Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John D Newell
- Department of Radiology, University of Iowa, Iowa City, Iowa
| | - Drew Torigian
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Edward Cantu
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Donna L Farber
- Department of Surgery, University of California at San Francisco, San Francisco, California; Columbia Center for Translational Immunology, Columbia University Medical Center, New York, New York; Department of Microbiology and Immunology, Columbia University Medical Center, New York, New York
| | - Jon T Giles
- Department of Medicine, Columbia University Medical Center, New York, New York
| | - Yubing Tong
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott Palmer
- Department of Medicine, Duke University & Duke Clinical Research Institute, Durham, North Carolina
| | - Lorraine B Ware
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wayne W Hancock
- Department of Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jason D Christie
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David J Lederer
- Department of Medicine, Columbia University Medical Center, New York, New York; Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, New York, New York.
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20
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Ranka S, Mohananey D, Agarwal N, Verma BR, Villablanca P, Mewhort HE, Ramakrishna H. Chronic Thromboembolic Pulmonary Hypertension-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:2513-2523. [PMID: 31883688 DOI: 10.1053/j.jvca.2019.11.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/11/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is rare but complex pathophysiological disease with hallmark features of chronic thrombotic mechanical obstruction, right ventricular dysfunction, and secondary pulmonary arteriopathy. It increasingly is being understood that chronic infection/inflammation, abnormal fibrinolysis, and cytokines play an important role in pathogenesis such that only a subset of patients with pulmonary embolism develop CTEPH. Diagnosis remains challenging given the lack of early clinical signs and overlap with other cardiopulmonary conditions. Pulmonary endarterectomy is the surgical procedure of choice with good postoperative survival and functional outcomes, especially when done at high-volume centers with a multidisciplinary approach. There has been a resurgence of balloon pulmonary angioplasty (BPA) as salvage therapy for inoperable CTEPH or in its newfound hybrid role for persistent postoperative pulmonary hypertension with excellent 1-year and 3-year survival. Use of riociguat has shown promising improvements in functional outcomes up to 2 years after initiation. Endothelin receptor antagonists serve a supplemental role postoperatively or in inoperable CTEPH. The role of drug therapy preoperatively or in tandem with BPA is currently under investigation.
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Affiliation(s)
- Sagar Ranka
- Department of Cardiovascular Medicine, Kansas University Medical Center, Kansas City, KS
| | - Divyanshu Mohananey
- Department of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Nikhil Agarwal
- Division of Cardiovascular Medicine, University of Buffalo, Buffalo, NY
| | - Beni Rai Verma
- Department of Cardiology, Cleveland Clinic, Cleveland, OH
| | | | | | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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21
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Magoon R, Karanjkar A, Kaushal B, Sharan S. Extravascular Lung Water Estimation for Prediction of Reperfusion Injury After Pulmonary Endarterectomy: A Closer Look. J Cardiothorac Vasc Anesth 2019; 34:1392-1393. [PMID: 31812564 DOI: 10.1053/j.jvca.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/01/2019] [Accepted: 11/08/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Rohan Magoon
- Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Ameya Karanjkar
- Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Brajesh Kaushal
- Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Sandeep Sharan
- Department of Cardiac Anesthesia, Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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22
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Mahmud E, Madani MM, Kim NH, Poch D, Ang L, Behnamfar O, Patel MP, Auger WR. Chronic Thromboembolic Pulmonary Hypertension: Evolving Therapeutic Approaches for Operable and Inoperable Disease. J Am Coll Cardiol 2019; 71:2468-2486. [PMID: 29793636 DOI: 10.1016/j.jacc.2018.04.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California.
| | - Michael M Madani
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, California
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - David Poch
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Omid Behnamfar
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Mitul P Patel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - William R Auger
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
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23
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Mahmud E, Behnamfar O, Ang L, Patel MP, Poch D, Kim NH. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Interv Cardiol Clin 2019; 7:103-117. [PMID: 29157517 DOI: 10.1016/j.iccl.2017.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with several risk factors but is most frequently seen as a rare consequence of an acute pulmonary embolism. Surgical pulmonary thromboendarterectomy (PTE) is potentially curative for CTEPH with the best outcomes seen for the treatment of primarily proximal, accessible lobar or segmental disease. For surgically inoperable patients, percutaneous balloon pulmonary angioplasty (BPA) is feasible and has good short- to mid-term efficacy outcomes. This review focuses on the technique and outcomes associated with BPA which has emerged as a new therapeutic option for CTEPH.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA.
| | - Omid Behnamfar
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA
| | - Lawrence Ang
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA
| | - Mitul P Patel
- Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA
| | - David Poch
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California, San Diego, 9434 Medical Center Drive, La Jolla, CA 92037, USA
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24
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Butchart AG, Zochios V, Villar SS, Jones NL, Curry S, Agrawal B, Jenkins DP, Klein AA. Measurement of extravascular lung water to diagnose severe reperfusion lung injury following pulmonary endarterectomy: a prospective cohort clinical validation study. Anaesthesia 2019; 74:1282-1289. [PMID: 31273760 PMCID: PMC6772184 DOI: 10.1111/anae.14744] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2019] [Indexed: 11/28/2022]
Abstract
The measurement of extravascular lung water is a relatively new technology which has not yet been well validated as a clinically useful tool. We studied its utility in patients undergoing pulmonary endarterectomy as they frequently suffer reperfusion lung injury and associated oedematous lungs. Such patients are therefore ideal for evaluating this new monitor. We performed a prospective observational cohort study during which extravascular lung water index measurements were taken before and immediately after surgery and postoperatively in intensive care. Data were analysed for 57 patients; 21 patients (37%) experienced severe reperfusion lung injury. The first extravascular lung water index measurement after cardiopulmonary bypass failed to predict severe reperfusion lung injury, area under the receiver operating characteristic curve 0.59 (95%CI 0.44–0.74). On intensive care, extravascular lung water index correlated most strongly at 36 h, area under the receiver operating characteristic curve 0.90 (95%CI 0.80–1.00). Peri‐operative extravascular lung water index is not a useful measure to predict severe reperfusion lung injury after pulmonary endarterectomy, however, it does allow monitoring and measurement during the postoperative period. This study implies that extravascular lung water index can be used to directly assess pulmonary fluid overload and that monitoring patients by measuring extravascular lung water index during their intensive care stay is useful and correlates with their clinical course. This may allow directed, pre‐empted therapy to attenuate the effects and improve patient outcomes and should prompt further studies.
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Affiliation(s)
- A G Butchart
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital, Cambridge, UK
| | - V Zochios
- Department of Intensive Care Medicine, University Hospitals Birmingham National Health Service Foundation Trust, Queen Elizabeth Hospital Birmingham, University of Birmingham, UK
| | - S S Villar
- MRC Biostatistics Unit, University of Cambridge School of Clinical Medicine, Cambridge Institute of Public Health, UK
| | - N L Jones
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital, Cambridge, UK
| | - S Curry
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital, Cambridge, UK
| | - B Agrawal
- Department of Radiology, Royal Papworth Hospital, Cambridge, UK
| | - D P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - A A Klein
- Department of Cardiothoracic Anaesthesia and Intensive Care Medicine, Royal Papworth Hospital, Cambridge, UK
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25
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Sanada TJ, Tanabe N, Ishibashi-Ueda H, Ishida K, Naito A, Sakao S, Suda R, Kasai H, Nishimura R, Sugiura T, Shigeta A, Taniguchi Y, Masuda M, Tatsumi K. Involvement of pulmonary arteriopathy in the development and severity of reperfusion pulmonary edema after pulmonary endarterectomy. Pulm Circ 2019; 9:2045894019846439. [PMID: 30957648 PMCID: PMC6540513 DOI: 10.1177/2045894019846439] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Reperfusion pulmonary edema (RPE) is a common complication after pulmonary
endarterectomy (PEA) in patients with chronic thromboembolic pulmonary
hypertension (CTEPH). However, the precise mechanisms underlying the development
of RPE remain unclear. To evaluate the effects of pulmonary vasculopathy on RPE,
the severity of the pulmonary arteriopathies and venopathies of lung tissues
biopsied during PEA were pathologically quantified in 33 CTEPH patients. The
severity of RPE was classified from grade 0 (no RPE) to 4 (death due to RPE)
based on the arterial oxygen tension/inspiratory oxygen fraction (P/F ratio) and
necessity of respiratory management. Among the 33 patients (27 women; mean
age = 63.3 years), 17 (51.5%) patients developed RPE. The severity of pulmonary
arteriopathy (obstruction ratio) correlated with the grade of RPE (r = 0.576,
P = 0.0005). The obstruction ratio also correlated with the
P/F ratio (r = −0.543, P = 0.001) and the perioperative mean
pulmonary arterial pressure (r = 0.445, P = 0.009).
Multivariate logistic regression analysis revealed that the obstruction ratio
was a significant independent determinant for the development of RPE (odds
ratio = 15.7; 95% confidence interval = 2.29–108.00,
P = 0.005). In conclusion, pulmonary arteriopathy could be a
determinant of the development and severity of RPE after PEA.
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Affiliation(s)
- Takayuki Jujo Sanada
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan.,2 Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nobuhiro Tanabe
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan.,2 Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hatsue Ishibashi-Ueda
- 3 Department of Pathology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Keiichi Ishida
- 4 Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Akira Naito
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Sakao
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Rika Suda
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hajime Kasai
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Rintaro Nishimura
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toshihiko Sugiura
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ayako Shigeta
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yu Taniguchi
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan.,5 Division of Cardiovascular Medicine, Kobe University Graduate School of Medicine, Chuo-Ku, Kobe, Japan
| | - Masahisa Masuda
- 4 Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koichiro Tatsumi
- 1 Department of Respirology (B2), Graduate School of Medicine, Chiba University, Chiba, Japan
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26
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Zhang J, Li J, Huang Z, Xu J, Fan Y. A meta‐analysis of randomized controlled trials in targeted treatments of chronic thromboembolic pulmonary hypertension. CLINICAL RESPIRATORY JOURNAL 2019; 13:467-479. [PMID: 31059198 DOI: 10.1111/crj.13034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 04/12/2019] [Accepted: 04/28/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Jing Zhang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jing‐Meng Li
- Department of Thoracic Surgery Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Zan‐Sheng Huang
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Jian‐Cheng Xu
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
| | - Ye Fan
- Department of Respiratory Disease Xinqiao Hospital, Third Military Medical University Chongqing China
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27
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Kratzert WB, Boyd EK, Saggar R, Channick R. Critical Care of Patients After Pulmonary Thromboendarterectomy. J Cardiothorac Vasc Anesth 2019; 33:3110-3126. [PMID: 30948200 DOI: 10.1053/j.jvca.2019.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 02/19/2019] [Accepted: 03/01/2019] [Indexed: 12/16/2022]
Abstract
Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.
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Affiliation(s)
- Wolf B Kratzert
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA.
| | - Eva K Boyd
- Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Rajan Saggar
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Richard Channick
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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28
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Yan S, Lou S, Zhu J, Liu S, Zhao Y, Song Y, Wang H, Ji B. Perfusion strategy and mid-term results of 58 consecutive pulmonary endarterectomy. Perfusion 2019; 34:475-481. [PMID: 30819040 DOI: 10.1177/0267659119831518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this retrospective study was to review and report short-term and mid-term outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at our institute in the recent 2 years and to describe perfusion strategy. METHODS A total of 58 consecutive patients with chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy under deep hypothermia circulatory arrest with an established perfusion practice between November 2015 and December 2017. Peri-operative data and patients' outcome were retrospectively analyzed. RESULTS Mean pulmonary artery pressure was decreased (49 (40-56) mmHg vs 27 (20-31) mmHg, p < 0.001), and pulmonary vascular resistance (724 (538-1108) vs 206 (141-284) dyn second cm-5, p < 0.001) improved significantly after surgery. In-hospital mortality was 1.7% and postoperative complication rate was 27.6%. Antipsychotic medication of olanzapine was prescribed for 36 patients (62.1%), which was independently related to total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit. The majority of patients recovered uneventfully with good mid-term cardiac function (New York Heart Association I-II: 98.1%) and neurological outcome (Glasgow Outcome Scale-Extended Upper Good Recovery: 74.1% and Lower Good Recovery: 20.3%). Mid-term neurological outcome was associated with post-pulmonary endarterectomy antipsychotic medication. CONCLUSION Short-term and mid-term outcome after pulmonary endarterectomy was comparable to high-volume centers. Incidence of post-pulmonary endarterectomy delirium was relatively high and associated with mid-term neurological outcome. Total deep hypothermic circulatory arrest time, postoperative blood potassium concentration, and hematocrit were independent risk factors of postoperative olanzapine medication. More efforts and further research are required to optimize the neuroprotection of perfusion practice.
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Affiliation(s)
- Shujie Yan
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Song Lou
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Jiade Zhu
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Yu Zhao
- New Era Stroke Care and Research Institute, The PLA Rocket Force General Hospital, Beijing, China
| | - Yunhu Song
- Department of Cardiovascular surgery, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Hui Wang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical science and Peking Union Medical College, Beijing, China
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29
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Ng O, Giménez-Milà M, Jenkins DP, Vuylsteke A. Perioperative Management of Pulmonary Endarterectomy-Perspective from the UK National Health Service. J Cardiothorac Vasc Anesth 2018; 33:3101-3109. [PMID: 30686656 DOI: 10.1053/j.jvca.2018.11.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Oriana Ng
- Division of Anaesthesiology, Singapore General Hospital, Singapore
| | - Marc Giménez-Milà
- Department of Anesthesia and Intensive Care, Hospital Universitari Bellvitge, Barcelona, Spain; Biomedical Research Institute of Bellvitge, Barcelona, Spain
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Alain Vuylsteke
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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Kamenskaya O, Klinkova A, Loginova I, Chernyavskiy A, Edemskiy A, Lomivorotov VV, Karaskov A. Determinants of Health-Related Quality of Life 1 Year after Pulmonary Thromboendarterectomy. Ann Vasc Surg 2018; 51:254-261. [PMID: 29678648 DOI: 10.1016/j.avsg.2018.02.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/15/2018] [Accepted: 02/05/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND Pulmonary thromboendarterectomy (PTE) is a recognized treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH), with good long-term hemodynamic results. The aim of this study was to test the hypothesis that the dynamics of health-related quality of life (QoL), 1 year after PTE, depend both on the clinical determinants associated with the underlying disease and the adverse events occurring in the early postoperative period. METHODS This prospective cohort study included 136 patients with CTEPH. All patients before and after PTE (1-year follow-up) were examined in terms of QoL, by using the Short Form 36 Health Survey Questionnaire. RESULTS One year after PTE, a significant improvement in the QoL of patients was observed in all subscales of the Short Form 36 Health Survey Questionnaire, except in the general health scale. Multivariate analysis showed that the predictors adversely affecting the dynamics of QoL after PTE were the presence of comorbidities (such as chronic obstructive pulmonary disease [COPD] and coronary artery disease) and early postoperative complications (specific ones for this category of patients are residual pulmonary hypertension and neurological complications, and nonspecific ones are atrial fibrillation and heart failure). CONCLUSIONS The determinants that affect the dynamics of QoL 1 year after PTE in patients with CTEPH were the presence of comorbidities (COPD and coronary artery disease) and adverse events in the early postoperative period (residual pulmonary hypertension, neurological complications, atrial fibrillation, and heart failure).
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Affiliation(s)
- Oksana Kamenskaya
- Department of Physiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Asya Klinkova
- Department of Physiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia.
| | - Irina Loginova
- Department of Physiology, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Alexander Chernyavskiy
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Alexander Edemskiy
- Department of Cardiac Surgery, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Vladimir V Lomivorotov
- Department of Anesthesia and Intensive Care, E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Alexander Karaskov
- E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
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Pak O, Sydykov A, Kosanovic D, Schermuly RT, Dietrich A, Schröder K, Brandes RP, Gudermann T, Sommer N, Weissmann N. Lung Ischaemia-Reperfusion Injury: The Role of Reactive Oxygen Species. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 967:195-225. [PMID: 29047088 DOI: 10.1007/978-3-319-63245-2_12] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Lung ischaemia-reperfusion injury (LIRI) occurs in many lung diseases and during surgical procedures such as lung transplantation. The re-establishment of blood flow and oxygen delivery into the previously ischaemic lung exacerbates the ischaemic injury and leads to increased microvascular permeability and pulmonary vascular resistance as well as to vigorous activation of the immune response. These events initiate the irreversible damage of the lung with subsequent oedema formation that can result in systemic hypoxaemia and multi-organ failure. Alterations in the production of reactive oxygen species (ROS) and reactive nitrogen species (RNS) have been suggested as crucial mediators of such responses during ischaemia-reperfusion in the lung. Among numerous potential sources of ROS/RNS within cells, nicotinamide adenine dinucleotide phosphate (NADPH) oxidases, xanthine oxidases, nitric oxide synthases and mitochondria have been investigated during LIRI. Against this background, we aim to review here the extensive literature about the ROS-mediated cellular signalling during LIRI, as well as the effectiveness of antioxidants as treatment option for LIRI.
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Affiliation(s)
- Oleg Pak
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany
| | - Akylbek Sydykov
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany
| | - Djuro Kosanovic
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany
| | - Ralph T Schermuly
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany
| | - Alexander Dietrich
- Walther-Straub-Institut für Pharmakologie und Toxikologie, Ludwig-Maximilians-Universität München, Goethestraße 33, 80336, Munich, Germany
| | - Katrin Schröder
- Institut für Kardiovaskuläre Physiologie, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Ralf P Brandes
- Institut für Kardiovaskuläre Physiologie, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany
| | - Thomas Gudermann
- Walther-Straub-Institut für Pharmakologie und Toxikologie, Ludwig-Maximilians-Universität München, Goethestraße 33, 80336, Munich, Germany
| | - Natascha Sommer
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany
| | - Norbert Weissmann
- Excellence Cluster Cardio-pulmonary System, University of Giessen Lung Center, German Center for Lung Research (DZL), Justus-Liebig-University Giessen, Aulweg 130, 35392, Giessen, Germany.
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Martino EA, Baiardo Redaelli M, Sardo S, Lembo R, Giordano VF, Winterton D, Ruggeri L, Hajjar LA, Zangrillo A, Landoni G. Steroids and Survival in Critically Ill Adult Patients: A Meta-analysis of 135 Randomized Trials. J Cardiothorac Vasc Anesth 2018; 32:2252-2260. [PMID: 29793761 DOI: 10.1053/j.jvca.2018.04.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Corticosteroids have important effects on intermediate outcomes in critically ill patients, but their effect on survival is unknown. The objective of this meta-analysis was to analyze the effect on mortality of corticosteroids in critical and perioperative settings. DESIGN A meta-analysis of randomized trials. SETTING PubMed, Embase, BioMed Central, Google Scholar, and the Cochrane Central Register of Controlled Trials were searched to February 1, 2018, for randomized trials comparing corticosteroids with placebo or standard care. PARTICIPANTS Critically ill or surgical adult patients. INTERVENTIONS Corticosteroids compared with placebo or standard care. MEASUREMENTS AND MAIN RESULTS A total of 44,553 patients from 135 studies were included. Overall, mortality in the corticosteroid group and in the control group were similar (16% v 16%; p = 0.9). Subanalyses identified a beneficial effect of corticosteroids on survival in patients with respiratory system diseases (9% v 13%; p < 0.001) and bacterial meningitis (28% v 32%; p= 0.04), and a detrimental effect on survival in patients with traumatic brain injury (22% v 19%; p < 0.001). No differences in mortality were found in patients with cardiac diseases (7% v 6%; p = 0.7), in patients undergoing cardiac surgery (2.8% v 3.2% p = 0.14), and when treatment duration or patient age were considered. CONCLUSIONS This meta-analysis documents the safety of corticosteroids in the overall critically ill population with the notable exception of brain injury patients, a setting where the authors confirmed their detrimental effect on survival. A possible beneficial effect of corticosteroids on survival was found among patients with respiratory diseases and in patients with bacterial meningitis.
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Affiliation(s)
- Enrico A Martino
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Salvatore Sardo
- Department of Medical Sciences "M. Aresu," University of Cagliari, Cagliari, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Vito F Giordano
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Winterton
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmilla A Hajjar
- Heart Institute (InCor), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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Dvirnik N, Belley-Cote E, Hanif H, Devereaux P, Lamy A, Dieleman J, Vincent J, Whitlock R. Steroids in cardiac surgery: a systematic review and meta-analysis. Br J Anaesth 2018; 120:657-667. [DOI: 10.1016/j.bja.2017.10.025] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 10/16/2017] [Accepted: 10/26/2017] [Indexed: 11/27/2022] Open
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Geng W, Nie Y, Huang S. Effects of methylprednisolone on the duration of rocuronium-induced neuromuscular block: A randomized double-blind trial. Medicine (Baltimore) 2017; 96:e7947. [PMID: 28953616 PMCID: PMC5626259 DOI: 10.1097/md.0000000000007947] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND We aim to investigate whether intraoperative use of methylprednisolone could affect the duration of rocuronium-induced neuromuscular blockade. METHODS A double blind, randomized, placebo-controlled trial was conducted. A total of 136 patients underwent gynecologic laparoscopic surgery were randomly divided into 3 groups: pregroup, receiving intravenous injection of methylprednisolone (40 mg) 30 minutes before induction of anesthesia; postgroup, receiving intravenous injection of methylprednisolone (40 mg) immediately after induction of anesthesia and intubation; and control group, receiving intravenous injection of normal saline. Patients were intravenously administrated with rocuronium 0.6 mg/kg, and changes in adductor policies evoked twitch responses were measured by ulnar nerve stimulator. RESULTS We found that all patients achieved maximum blockade effects, and there was no difference in onset time among the 2 groups. For time required to achieve train-of-four ratio (TOFR) 90%, pregroup (64.50 ± 10.52 minutes) and postgroup (65.29 ± 11.64 minutes) were significantly shorter than that of the control group (71.04 ± 10.55 minutes, P = .027), whereas clinical duration and total duration were significantly shorter in the 2 groups received methylprednisolone than the control group. However, there was no significant difference between the 2 treatment groups either in clinical duration and total duration of muscle relaxants, or time required to achieve TOFR 90%. No significant difference was found in recovery index among the 3 groups. CONCLUSION Our findings suggest that a single intravenous injection of methylprednisolone, no matter preoperatively or intraoperatively, could shorten the duration of rocuronium-induced neuromuscular blockade.
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Evaluation of Reperfusion Pulmonary Edema by Extravascular Lung Water Measurements After Pulmonary Endarterectomy. Crit Care Med 2017; 45:e409-e417. [DOI: 10.1097/ccm.0000000000002259] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Beltrán-Gámez ME, Sandoval-Zárate J, Pulido T. De la tromboembolia pulmonar aguda a la hipertensión pulmonar tromboembólica crónica: implicaciones en la patobiología y fisiopatología. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:26-34. [DOI: 10.1016/j.acmx.2016.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 10/20/2022] Open
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Efficacy of a Low-Tidal Volume Ventilation Strategy to Prevent Reperfusion Lung Injury after Pulmonary Thromboendarterectomy. Ann Am Thorac Soc 2016; 12:1520-7. [PMID: 26241077 DOI: 10.1513/annalsats.201503-142oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
RATIONALE Reperfusion lung injury is a postoperative complication of pulmonary thromboendarterectomy that can significantly affect morbidity and mortality. Studies in other postoperative patient populations have demonstrated a reduction in acute lung injury with the use of a low-tidal volume (Vt) ventilation strategy. Whether this approach benefits patients undergoing thromboendarterectomy is unknown. OBJECTIVES We sought to determine if low-Vt ventilation reduces reperfusion lung injury in patients with chronic thromboembolic pulmonary hypertension undergoing thromboendarterectomy. METHODS Patients undergoing thromboendarterectomy at one center were randomized to receive either low (6 ml/kg predicted body weight) or usual care Vts (10 ml/kg) from the initiation of mechanical ventilation in the operating room through Postoperative Day 3. The primary endpoint was the onset of reperfusion lung injury. Secondary outcomes included severity of hypoxemia, days on mechanical ventilation, and intensive care unit and hospital lengths of stay. MEASUREMENTS AND MAIN RESULTS A total of 128 patients were enrolled and included in the analysis; 63 were randomized to the low-Vt group and 65 were randomized to the usual care group. There was no statistically significant difference in the incidence of reperfusion lung injury between groups (32%, n=20 in the low-Vt group vs. 23%, n=15 in the usual care group; P=0.367). Although differences were noted in plateau pressures (17.9 cm H2O vs. 20.1 cm H2O, P<0.001) and peak inspiratory pressures (20.4 cm H2O vs. 23.0 cm H2O, P<0.001) between the low-Vt and usual care groups, respectively, mean airway pressures, PaO2/FiO2, days on mechanical ventilation, and ICU and hospital lengths of stay were all similar between groups. CONCLUSIONS In patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy, intra- and postoperative ventilation using low Vts (6 mg/kg) compared with usual care Vts (10 mg/kg) does not reduce the incidence of reperfusion lung injury or improve clinical outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT00747045).
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Guth S, Wiedenroth CB, Kramm T, Mayer E. Pulmonary endarterectomy for the treatment of chronic thromboembolic pulmonary hypertension. Expert Rev Respir Med 2016; 10:673-84. [PMID: 27070482 DOI: 10.1080/17476348.2016.1176915] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary endarterectomy is a curative treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). There is a growing body of evidence suggesting that not only patients with CTEPH but also patients with pulmonary arterial obstructions and mean pulmonary artery pressures < 25 mmHg should be offered surgery. In this review, the recent literature regarding pathophysiology, diagnostic methods, decision making by an expert CTEPH team, and surgical techniques will be summarized. Novel alternative treatment options for inoperable CTEPH patients will be discussed, i.e. targeted medical therapy and balloon pulmonary angioplasty. For the future the major task will be to define a clear selection process for the optimal treatment of the individual CTEPH patient.
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Affiliation(s)
- Stefan Guth
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Christoph B Wiedenroth
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Thorsten Kramm
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Eckhard Mayer
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
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Hoogma D, Meyns B, Van Raemdonck D, Van de Velde M, Missant C, Rex S. Anesthetic Management for Resection of Bilateral Pulmonary Artery Sarcoma. ACTA ACUST UNITED AC 2016; 5:64-8. [PMID: 26275309 DOI: 10.1213/xaa.0000000000000181] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe a patient who presented with a bilateral pulmonary artery sarcoma, initially treated as pulmonary embolism, that necessitated concomitant pulmonary endarterectomy and pneumonectomy. We reviewed the anesthetic management used for this procedure, which bears many similarities to the management of patients undergoing pulmonary thromboendarterectomy. Right ventricular failure, pulmonary hemorrhage, and cerebral ischemia due to circulatory arrest are life-threatening perioperative complications. The anesthesiologist can play a key role in the prevention (or timely recognition and treatment) of these perioperative complications by establishing adequate hemodynamic, echocardiographic, and neurologic monitoring and by optimizing cardiopulmonary function and coagulation.
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Affiliation(s)
- Danny Hoogma
- From the Departments of *Anesthesiology, and †Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium; ‡Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium; and §Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
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Bartko J, Stiebellehner L, Derhaschnig U, Schoergenhofer C, Schwameis M, Prosch H, Jilma B. Dissociation between systemic and pulmonary anti-inflammatory effects of dexamethasone in humans. Br J Clin Pharmacol 2016; 81:865-77. [PMID: 26647918 PMCID: PMC4834593 DOI: 10.1111/bcp.12857] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Revised: 11/23/2015] [Accepted: 12/01/2015] [Indexed: 12/14/2022] Open
Abstract
Aims The local pulmonary inflammatory response has a different temporal and qualitative profile compared with the systemic inflammatory response. Although glucocorticoids substantially downregulate the systemic release of acute‐phase mediators, it is not clear whether they have comparable inhibitory effects in the human lung compartment. Therefore, we compared the anti‐inflammatory effects of a pure glucocorticoid agonist, dexamethasone, on bronchoalveolar lavage and blood cytokine concentrations in response to bronchially instilled endotoxin. Methods In this randomized, double‐blind and placebo‐controlled trial, 24 volunteers received dexamethasone or placebo and had endotoxin instilled into a lung segment and saline instilled into a contralateral segment, followed by bronchoalveolar lavage. Results Bronchially instilled endotoxin induced a local and systemic inflammatory response. Dexamethasone strongly blunted the systemic interleukin (IL) 6 and C‐reactive protein release. In sharp contrast, dexamethasone left the local release of acute‐phase mediators in the lungs virtually unchanged: bronchoalveolar lavage levels of IL‐6 were only 18% lower and levels of IL‐8 were even higher with dexamethasone compared with placebo, although the differences between treatments were not statistically significant (P = 0.07 and P = 0.08, respectively). However, dexamethasone had inhibitory effects on pulmonary protein extravasation and neutrophil migration. Conclusions The present study demonstrated a remarkable dissociation between the systemic anti‐inflammatory effects of glucocorticoids and its protective effects on capillary leak on the one hand and surprisingly low anti‐inflammatory effects in the lungs on the other.
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Affiliation(s)
- Johann Bartko
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | | | - Ulla Derhaschnig
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Michael Schwameis
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Helmut Prosch
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Jenkins D. Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2015; 24:263-71. [PMID: 26028638 PMCID: PMC9487822 DOI: 10.1183/16000617.00000815] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is a complex surgical procedure with a simple principle: removal of obstructive thromboembolic material from the pulmonary arteries in order to reduce pulmonary vascular resistance, relieve pulmonary hypertension (PH) and alleviate right ventricular dysfunction. In the majority of patients there is symptomatic and prognostic benefit. However, not all patients with CTEPH are suitable for treatment with PEA. Operability assessment is not always easy, being largely subjective and based on experience. It is therefore important that all patients are referred to an experienced CTEPH centre for careful evaluation of suitability for surgery. The most common reason for inoperability is distal vasculopathy accounting for a high proportion of the vascular resistance. Surgery requires cardiopulmonary bypass and periods of deep hypothermic circulatory arrest. Complications include reperfusion lung injury and persistent PH. However, with careful patient selection, surgical technique and post-operative management, PEA is a highly effective treatment with mortality rates <5% at experienced centres. Patients who are unsuitable for surgery may be candidates for medical therapy. A review of pulmonary endarterectomy as a CTEPH treatment, including patient assessment, risks and outcomeshttp://ow.ly/L82F7
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Ogawa A, Matsubara H. Balloon Pulmonary Angioplasty: A Treatment Option for Inoperable Patients with Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2015; 2:4. [PMID: 26664876 PMCID: PMC4671397 DOI: 10.3389/fcvm.2015.00004] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 02/01/2015] [Indexed: 12/20/2022] Open
Abstract
In chronic thromboembolic pulmonary hypertension (CTEPH), stenoses or obstructions of the pulmonary arteries due to organized thrombi can cause an elevation in pulmonary artery resistance, which in turn can result in pulmonary hypertension. CTEPH can be cured surgically by pulmonary endarterectomy (PEA); however, patients deemed unsuitable for PEA due to lesion, advanced age, or comorbidities have a poor prognosis and limited treatment options. Recently, advances have been made in balloon pulmonary angioplasty for these patients, and this review highlights this recent progress.
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Affiliation(s)
- Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center , Okayama , Japan
| | - Hiromi Matsubara
- Department of Clinical Science, National Hospital Organization Okayama Medical Center , Okayama , Japan
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Schölzel BE, Snijder RJ, Mager JJ, van Es HW, Plokker HWM, Reesink HJ, Morshuis WJ, Post MC. Chronic thromboembolic pulmonary hypertension. Neth Heart J 2014; 22:533-41. [PMID: 25169577 PMCID: PMC4391185 DOI: 10.1007/s12471-014-0592-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Chronic pulmonary thromboembolic disease is an important cause of severe pulmonary hypertension, and as such is associated with significant morbidity and mortality. The prognosis of this condition reflects the degree of associated right ventricular dysfunction, with predictable mortality related to the severity of the underlying pulmonary hypertension. Left untreated, the prognosis is poor. Pulmonary endarterectomy is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension and has been remarkably successful. Advances in surgical techniques along with the introduction of pulmonary hypertension-specific medication provide therapeutic options for the majority of patients afflicted with the disease. However, a substantial number of patients are not candidates for pulmonary endarterectomy due to either distal pulmonary vascular obstruction or significant comorbidities. Therefore, careful selection of surgical candidates in expert centres is paramount. The current review focuses on the diagnostic approach to chronic thromboembolic pulmonary hypertension and the available surgical and medical therapeutic options.
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Affiliation(s)
- B. E. Schölzel
- Department of Cardiology, Amphia Hospital, Molengracht 21, 4818 CK Breda, the Netherlands
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - R. J. Snijder
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - J. J. Mager
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H W. van Es
- Department of Radiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. W. M. Plokker
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - H. J. Reesink
- Department of Pulmonology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - W. J. Morshuis
- Department of Cardio-Thoracic Surgery, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
| | - M. C. Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3425 CM Nieuwegein, the Netherlands
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Banks DA, Pretorius GVD, Kerr KM, Manecke GR. Pulmonary Endarterectomy. Semin Cardiothorac Vasc Anesth 2014; 18:331-40. [DOI: 10.1177/1089253214537688] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from recurrent or incomplete resolution of pulmonary embolism. CTEPH is much more common than generally appreciated. Although pulmonary embolism (PE) affects a large number of Americans, chronic pulmonary thromboembolic hypertension remains underdiagnosed. It is imperative that all patients with pulmonary hypertension (PH) be screened for the presence of CTEPH since this form of PH is potentially curable with pulmonary endarterectomy (PEA) surgery. The success of this procedure depends greatly on the collaboration of a multidisciplinary team approach that includes pulmonary medicine, cardiothoracic surgery, and cardiac anesthesiology. This review, based on the experience of more than 3000 pulmonary endarterectomy surgeries, is divided into 2 parts. Part I focuses on the clinical history and pathophysiology, diagnostic workup, and intraoperative echocardiography. Part II focuses on the surgical approach, anesthetic management, postoperative care, and complications.
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Affiliation(s)
| | | | - Kim M. Kerr
- University of California, San Diego, San Diego, CA, USA
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Steroids for surgery during cardiopulmonary bypass in adults: a meta-analysis. J Clin Anesth 2014; 26:36-45. [PMID: 24439905 DOI: 10.1016/j.jclinane.2013.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Revised: 08/29/2013] [Accepted: 08/29/2013] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of steroid administration on myocardial infarction (MI), stroke, renal insufficiency, death, intensive care (ICU) length of stay (LOS) and hospital LOS of patients undergoing cardiopulmonary bypass (CPB). DESIGN Meta-analysis of parallel randomized controlled trials. SETTING University hospital. MEAUREMENTS A search was conducted in PubMed, EMBASE, MEDLINE(R) and the Cochrane Central Register of Controlled Trials of studies on adults undergoing surgery with CPB who received steroid administration. Effect size (risk ratio or mean difference) for MI, stroke, renal insufficiency, death, ICU LOS, and hospital LOS were evaluated. MAIN RESULTS 48 RCTs published between 1977 and 2012 were retained for analysis. Steroids had no effect on the MI risk ratio (RR) 0.91 (95% confidence interval [CI] 0.63, 1.32); death at 30 days RR 0.84 (0.59, 1.20); stroke RR 0.92 (0.60, 1.42) or renal insufficiency RR 0.83 (0.52, 1.32). Administration of steroids reduced ICU LOS (P = 0.00001; I(2) 87.5%) and hospital LOS (P = 0.03; I(2) 81.1%). Metaregressions showed that duration of steroid administration was correlated with the reduction in ICU LOS (P = 0.0004) and hospital LOS (P < 0.00001). CONCLUSIONS Increasing the duration of steroid administration may reduce ICU and hospital LOS greater than increasing the dose.
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Poch D, Pretorius V. Pulmonary Endarterectomy: Assessment of Operability, Surgical Description, and Post-op Care. ACTA ACUST UNITED AC 2014. [DOI: 10.21693/1933-088x-12.4.186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is defined as a mean pulmonary artery pressure ≥25 mm Hg and pulmonary artery wedge pressure ≤15 mm Hg in the presence of occlusive thrombi within the pulmonary arteries. Surgical pulmonary thromboendarterectomy (PTE) is considered the best treatment option for CTEPH.
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Affiliation(s)
- David Poch
- Division of Pulmonary and Critical Care, University of California San Diego, La Jolla, CA
| | - Victor Pretorius
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, CA
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Ju NY, Gao H, Huang W, Niu FF, Lan WX, Li F, Gao W. Therapeutic effect of inhaled budesonide (Pulmicort®Turbuhaler) on the inflammatory response to one-lung ventilation. Anaesthesia 2013; 69:14-23. [PMID: 24164087 DOI: 10.1111/anae.12479] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2013] [Indexed: 01/15/2023]
Affiliation(s)
- N. Y. Ju
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - H. Gao
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - W. Huang
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - F. F. Niu
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - W. X. Lan
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - F. Li
- Department of Intensive Care Medicine; The Third Affiliated Hospital of Harbin Medical University; Harbin China
| | - W. Gao
- Department of Anaesthesiology; The Second Affiliated Hospital of Harbin Medical University; Harbin China
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Ogino H. Recent advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension including Japanese experiences. Gen Thorac Cardiovasc Surg 2013; 62:9-18. [DOI: 10.1007/s11748-013-0323-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/25/2022]
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Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv 2012. [PMID: 23192917 DOI: 10.1161/circinterventions.112.971077] [Citation(s) in RCA: 407] [Impact Index Per Article: 33.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Although balloon pulmonary angioplasty (BPA) for inoperable patients with chronic thromboembolic pulmonary hypertension was first reported over a decade ago, its clinical application has been restricted because of limited efficacy and complications. We have refined the procedure of BPA to maximize its clinical efficacy. METHODS AND RESULTS Sixty-eight consecutive patients with inoperable chronic thromboembolic pulmonary hypertension underwent BPA. We evaluated pulmonary artery diameters and determined the appropriate balloon size by using intravascular ultrasound. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. A total of 4 (2-8) sessions were performed in each patient, and the number of vessels dilated per session was 3 (1-14). The World Health Organization functional class improved from 3 to 2 (P<0.01), and mean pulmonary arterial pressure was decreased from 45.4 ± 9.6 to 24.0 ± 6.4 mm Hg (P<0.01). One patient died because of right heart failure 28 days after BPA. During follow-up for 2.2 ± 1.4 years after the final BPA, another patient died of pneumonia, and the remaining 66 patients are alive. In 57 patients who underwent right heart catheterization at follow-up, improvement of mean pulmonary arterial pressure was maintained (24.0 ± 5.8 mm Hg at 1.0 ± 0.9 years). Forty-one patients (60%) developed reperfusion pulmonary injury after BPA, but mechanical ventilation was required in only 4 patients. CONCLUSIONS Our refined BPA procedure improves clinical status and hemodynamics of inoperable patients with chronic thromboembolic pulmonary hypertension, with a low mortality. A refined BPA procedure could be considered as a therapeutic approach for patients with inoperable chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Hiroki Mizoguchi
- Division of Cardiology, National Hospital Organization Okayama Medical Center, Japan
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