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Hoyos R, Lichtblau M, Cajamarca E, Mayer L, Schwarz EI, Ulrich S. Characteristics and risk profiles of patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension living permanently at >2500 m of high altitude in Ecuador. Pulm Circ 2024; 14:e12404. [PMID: 38974936 PMCID: PMC11224915 DOI: 10.1002/pul2.12404] [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: 09/17/2023] [Revised: 05/09/2024] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
Over 80 Mio people worldwide live >2500 m, including at least as many patients with pulmonary vascular disease (PVD), defined as pulmonary arterial or chronic thromboembolic pulmonary hypertension (PAH/CTEPH), as elsewhere (estimated 0.1‰). Whether PVD patients living at high altitude have altered disease characteristics due to hypobaric hypoxia is unknown. In a cross-sectional study conducted at the Hospital Carlos Andrade Marin in Quito, Ecuador, located at 2840 m, we included 36 outpatients with PAH or CTEPH visiting the clinic from January 2022 to July 2023. We collected data on diagnostic right heart catheterization, treatment, and risk factors, including NYHA functional class (FC), 6-min walk distance (6MWD), and NT-brain natriuretic peptide (BNP) at baseline and at last follow-up. Thirty-six PVD patients (83% women, 32 PAH, 4 CTEPH, mean ± SD age 44 ± 13 years, living altitude 2831 ± 58 m) were included and had the following baseline values: PaO2 8.2 ± 1.6 kPa, PaCO2 3.9 ± 0.5 kPa, SaO2 91 ± 3%, mean pulmonary artery pressure 53 ± 16 mmHg, pulmonary vascular resistance 16 ± 4 WU, 50% FC II, 50% FC III, 6MWD 472 ± 118 m, BNP 490 ± 823 ng/L. Patients were treated for 1628 ± 1186 days with sildenafil (100%), bosentan (33%), calcium channel blockers (33%), diuretics (69%), and oxygen (nocturnal 53%, daytime 11%). Values at last visit were: FC (II 75%, III 25%), 6MWD of 496 ± 108 m, BNP of 576 ± 5774 ng/L. Compared to European PVD registries, ambulatory PVD patients living >2500 m revealed similar blood gases and relatively low and stable risk factor profiles despite severe hemodynamic compromise, suggesting that favorable outcomes are achievable for altitude residents with PVD. Future studies should focus on long-term outcomes in PVD patients dwelling >2500 m.
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Affiliation(s)
| | - Mona Lichtblau
- Department of PulmonologyUniversity Hospital ZurichZurichSwitzerland
| | | | - Laura Mayer
- Department of PulmonologyUniversity Hospital ZurichZurichSwitzerland
| | | | - Silvia Ulrich
- Department of PulmonologyUniversity Hospital ZurichZurichSwitzerland
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Pérez‐Peñate GM, Juliá‐Serdá G, Galván‐Fernández H, Alemán‐Segura D, León‐Marrero F, Garcia‐Quintana A, de Larrinoa IR, Ortega‐Trujillo JR, Gómez‐Sánchez MÁ. Safety of inhaled nitric oxide withdrawal in severe chronic pulmonary hypertension. Pulm Circ 2024; 14:e12344. [PMID: 38468631 PMCID: PMC10925723 DOI: 10.1002/pul2.12344] [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: 08/23/2023] [Revised: 01/15/2024] [Accepted: 01/26/2024] [Indexed: 03/13/2024] Open
Abstract
Inhaled nitric oxide (iNO) is a potent and selective pulmonary vasodilator with a safety concern due to rebound pulmonary hypertension (PH) associated with its withdrawal. We report short-term pulsed iNO in patients with severe pulmonary arterial hypertension (PAH) and nonoperable chronic thromboembolic PH (nCTEPH). This is a retrospective analysis of 33 patients: 22 with PAH and 11 with nCTEPH. We assessed hemodynamic, echocardiographic, and other noninvasive variables to evaluate safety and efficacy of iNO. We performed an iNO withdrawal test during right heart catheterization and after 3 days of iNO treatment. iNO significantly improved all variables examined in 22 patients with PAH and 11 with nCTEPH. Two patterns of response were observed after sudden iNO withdrawal. Twenty-nine patients (88%) showed minimal hemodynamic, oxygenation and clinical changes. Four patients (12%) had a reduction in cardiac index ≥20% and PaO2 ≥ 5%, three patients did not show clinical deterioration, and one patient developed hemodynamic collapse that needed iNO administration. This retrospective study suggests that short-term iNO improves hemodynamics and clinical conditions in some patients with PAH an nCTPEH. However, pulsed iNO withdrawal PH rebound could be a serious concern in these patients. Given the lack of evidence, we do not recommend the use of pulsed iNO in the treatment of patients with chronic PH.
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Affiliation(s)
- Gregorio Miguel Pérez‐Peñate
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos IIIMadridSpain
| | - Gabriel Juliá‐Serdá
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Helena Galván‐Fernández
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Desireé Alemán‐Segura
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | - Fernando León‐Marrero
- Department of Respiratory MedicineMultidisciplinary Pulmonary Vascular Unit, Hospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
| | | | | | | | - Miguel Ángel Gómez‐Sánchez
- Department of RheumatologyHospital Universitario Dr. NegrínLas Palmas de Gran CanariaSpain
- Department of CardiologyCentro Médico EboraSaludTalavera de la ReinaToledoSpain
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Frantz RP, Leopold JA, Hassoun PM, Hemnes AR, Horn EM, Mathai SC, Rischard FP, Larive AB, Tang WW, Park MM, Hill NS, Rosenzweig EB. Acute vasoreactivity testing during right heart catheterization in chronic thromboembolic pulmonary hypertension: Results from the pulmonary vascular disease phenomics study. Pulm Circ 2023; 13:e12181. [PMID: 36618713 PMCID: PMC9817070 DOI: 10.1002/pul2.12181] [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: 08/18/2022] [Revised: 09/29/2022] [Accepted: 12/11/2022] [Indexed: 12/24/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is believed to involve both vascular obstruction and vasoconstriction; hence, pulmonary vasodilators such as riociguat may be beneficial. Acute vasoreactivity testing (AVT) is seldom performed routinely in CTEPH patients, so there is limited understanding of the frequency and significance of an acute vasodilator response. Systematic vasodilator testing with oxygen (O2) and oxygen plus inhaled nitric oxide (O2 + iNO) was performed as part of the Pulmonary Vascular Disease Omics (PVDOMICS) NHLBI project, providing an opportunity to examine AVT responses in CTEPH. Patients with CTEPH enrolled in PVDOMICS (n = 49, 40 with prevalent CTEPH [82%]) underwent right heart catheterization including AVT with O2 and O2 + iNO. Hemodynamics were obtained at baseline and with each challenge. Fourteen of 49 patients (29%) had >20% drop in pulmonary vascular resistance (PVR) with O2. With O2 + iNO, 30/49 (61%) had >20% drop in PVR, 20% had >20% drop in mean pulmonary artery pressure (mPAP) and PVR, and 8% had >10 mmHg decline in mPAP to mPAP < 40 with normal cardiac output. Patients on riociguat had less response to O2 + iNO than patients on phosphodiesterase-5 inhibitors. Our findings shed light on the significant variability in vascular tone that is present in CTEPH, confirming that CTEPH represents a combination of mechanical obstruction and vasoconstriction that appears similar to that observed with Group 1 PAH. Additional study regarding whether results of acute vasodilator testing predict response to therapy and relate to prognosis is warranted.
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Affiliation(s)
- Robert P. Frantz
- Department of Cardiovascular MedicineMayo ClinicRochesterMinnesotaUSA
| | | | - Paul M. Hassoun
- Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Evelyn M. Horn
- Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Stephen C. Mathai
- Division of Pulmonary and Critical Care MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
| | - Franz P. Rischard
- Perkin Heart Failure Center, Division of CardiologyWeill Cornell MedicineNew YorkNew YorkUSA
| | - A. Brett Larive
- Department of Quantitative Health SciencesCleveland ClinicClevelandOhioUSA
| | - W.h. Wilson Tang
- Department of Cardiovascular MedicineCleveland ClinicClevelandOhioUSA
| | - Margaret M. Park
- Department of Cardiovascular MedicineCleveland ClinicClevelandOhioUSA
| | - Nicholas S. Hill
- Division of Pulmonary, Critical Care, and Sleep MedicineTufts Medical CenterBostonMassachusettsUSA
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Zare E, Kafshbani P, Chenaghlou M, Noori M, Ghaemmaghami Z, Amin A, Taghavi S, Naderi N. Prognostic significance of insulin resistance in pulmonary hypertension. ESC Heart Fail 2022; 9:318-326. [PMID: 34904389 PMCID: PMC8788000 DOI: 10.1002/ehf2.13752] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Revised: 07/31/2021] [Accepted: 11/24/2021] [Indexed: 11/08/2022] Open
Abstract
AIMS The relationship between insulin resistance (IR) and glucose intolerance with pulmonary hypertension (PH) has been suggested in recent investigations. In the present study, we aimed to show the prevalence of IR and its correlation with haemodynamic variables as well as its prognostic significance in this group of patients. METHODS AND RESULTS Among 100 new and returning patients with PH, scheduled for right heart catheterization (RHC), 59 non-diabetic patients were enrolled. The homeostasis model assessment of insulin resistance (HOMA-IR) was used to assess IR. The study population were followed up for a median (interquartile range) of 48 (23-48) months for all-cause mortalities. Most of the study population [mean (standard deviation) age of 45.9 (17.3)] were classified as class I of PH classification (47.5%). Overall, 27% of our study population had IR considering the Iranian cut points of HOMA-IR. The prevalence of IR in non-diabetic, non-metabolic syndrome patients with precapillary PH (PAH) was 34.2%, which was higher than the prevalence of IR in non-diabetic, non-metabolic syndrome Iranian population (24.1%). There was no difference between IR and insulin sensitive (IS) groups regarding demographic and clinical findings, 6 min walk test, and laboratory and haemodynamic data in univariable and multivariable analyses. The mortality rate in the follow-up period was 44.1%. The survival of patient with IR was slightly lower than IS patients; however, IR was not an independent predictor of death. CONCLUSIONS The glucose metabolism is dysregulated in patients with PH, and IR may increase the risk of adverse events among these patients.
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Affiliation(s)
- Elahe Zare
- Yazd Cardiovascular Research CenterShahid Sadoughi University of Medical SciencesYazdIran
| | - Parvaneh Kafshbani
- Rajaie Cardiovascular Research CenterIran University of Medical SciencesTehranIran
| | - Maryam Chenaghlou
- Cardiovascular Research CenterTabriz University of Medical SciencesTehranIran
| | - Mehdi Noori
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Zahra Ghaemmaghami
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Ahmad Amin
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Sepideh Taghavi
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
| | - Nasim Naderi
- Rajaie Cardiovascular Medical and Research CenterIran University of Medical SciencesTehranIran
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Saito S, Ikeda N, Iijima R, Hara H, Nakamura M. Evaluation of the effect of nitric oxide inhalation in the patients with chronic thromboembolic pulmonary hypertension or pulmonary disease during balloon pulmonary angioplasty. Pulm Circ 2022; 12:e12032. [PMID: 35506109 PMCID: PMC9053008 DOI: 10.1002/pul2.12032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/28/2021] [Accepted: 12/26/2021] [Indexed: 11/25/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) or pulmonary disease (CTEPD) is performed worldwide. High mean pulmonary arterial pressure (mPAP) during BPA is associated with aggravation of procedure‐related complications. Inhaled nitric oxide (NO) acts as a pulmonary vasodilator in CTEPH patients. The aim of this retrospective observational study was to evaluate the effects of inhaled NO in CTEPH/CTEPD patients during BPA. We assessed hemodynamic changes and the frequency of procedure‐related complications with or without NO inhalation. We performed 338 consecutive BPA in 72 CTEPH/CTEPD patients between April 2016 and November 2020. Since December 2019, all 16 patients (72‐BPA sessions) inhaled NO during the procedure as a routine. Inhaled NO significantly reduced mPAP from 31.3 ± 8.5 to 27.2 ± 6.8 mmHg (p < 0.001) without lowering systemic blood pressure (systolic: 139.9 ± 19.9 vs. 135.3 ± 21.8 mmHg; p = 0.247, diastolic: 82.8 ± 13.0 vs. 79.0 ± 9.3 mmHg; p = 0.085, before vs. after NO inhalation, respectively). Procedure‐related complications were observed in 46 sessions (13.6%). The incidence of hemoptysis was significantly higher in the NO group than in the non‐NO group (20.8% vs. 10.9%; p = 0.031). In contrast, all fatal complications (death and use of positive pressure ventilation) occurred in the non‐NO group, but the difference was not statistically significant (0 sessions [0.0%] vs. 7 sessions [2.6%], p = 0.353). Inhaled NO acts as a selective pulmonary vasodilator in CTEPH/CTEPD patients during the BPA procedure.
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Affiliation(s)
- Shota Saito
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Raisuke Iijima
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Hidehiko Hara
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
| | - Masato Nakamura
- Division of Cardiovascular Medicine Toho University Ohashi Medical Center Tokyo Japan
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Shigetoshi M, Hatanaka K, Ogawa A, Tabuchi I, Shimokawahara H, Munemasa M, Ito H, Matsubara H. Oxygen inhalation can selectively dilate pulmonary arteries in patients with chronic thromboembolic pulmonary hypertension before balloon angioplasty. J Cardiol 2021; 79:265-269. [PMID: 34563438 DOI: 10.1016/j.jjcc.2021.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/22/2021] [Accepted: 08/31/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pulmonary injury is a major complication of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH). Lung injury after BPA can be exacerbated by a high mean pulmonary arterial pressure (PAP). Although oxygen inhalation is expected to lower mean PAP in patients with CTEPH, no relevant investigation has been conducted. METHODS Consecutive patients with CTEPH who underwent BPA were enrolled in this study. We evaluated the hemodynamics using right heart catheterization while breathing ambient air and with administration of 5 L/min oxygen for 10 min. RESULTS This study included 52 consecutive patients with CTEPH, of whom 23 (44%) were treated with specific pulmonary vasodilators. Exposure to oxygen was well tolerated. Oxygen administration significantly decreased mean PAP by 3.8 ± 3.2 mmHg (p<0.001) and pulmonary vascular resistance by 0.8 ± 1.8 Wood units (p<0.001). Moreover, the ratio of pulmonary vascular resistance to systemic vascular resistance was significantly reduced by 13.5% (p<0.001). Multivariate regression analysis identified baseline mean PAP (β = -0.427, p = 0.006) as the only significant predictor of decreased mean PAP under oxygen administration. No significant difference in oxygen effect on mean PAP was found between patients with and without vasodilators. CONCLUSIONS In patients with CTEPH, 5 L/min supplemental oxygen inhalation could decrease mean PAP significantly by selective pulmonary artery dilatation, regardless of the usage of vasodilators, and thus could be helpful to maximize the safety of BPA. CLINICAL TRIAL REGISTRATION UMIN Clinical Trials Registry (No.: UMIN000026882); URL: https://www.umin.ac.jp/ctr/index.htm.
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Affiliation(s)
- Masataka Shigetoshi
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Kunihiko Hatanaka
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Isao Tabuchi
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Mitsuru Munemasa
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan.
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Comparative Efficacy and Safety of Targeted Therapies for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Network Meta-Analysis. Can Respir J 2021; 2021:1626971. [PMID: 34512819 PMCID: PMC8426079 DOI: 10.1155/2021/1626971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 08/03/2021] [Accepted: 08/25/2021] [Indexed: 11/17/2022] Open
Abstract
Background There is significant controversy relating to whether chronic thromboembolic pulmonary hypertension (CTEPH) can be treated with pulmonary arterial hypertension- (PAH-) targeted therapies and which therapy is the optimal choice for patients. A large number of randomized controlled trials (RCTs) have compared PAH-targeted therapies with placebo or conventional therapies. In this study, we aimed to compare all of the PAH-targeted medications that are used to treat CTEPH and rank their efficacy by the application of network meta-analysis (NMA). Methods We searched PubMed, EMBASE, Web of Science, the Cochrane Central Register, https://clinicaltrials.gov, and who.int/trialsearch/, for relevant RCTs published up to January 2020. In addition to traditional meta-analysis, we also performed NMA in our systematic review, as deployed in a previous protocol (PROSPERO: CRD42020173765). Results Our study identified eight eligible RCTs that evaluated seven PAH-targeted therapies in 703 patients with CTEPH. NMA revealed that riociguat was ranked first as the most optimized therapy for ameliorating the 6-minute walk distance with a probability of 80.4%. Bosentan was significantly better than others with regard to reducing brain natriuretic peptide/N-terminal pro-B-type natriuretic peptide with a probability of 84.3%. Sildenafil was identified as the best drug in terms of improving the New York Heart Association/World Health Organization functional class with a probability of 87.3%. Treprostinil and macitentan were more beneficial than other drugs in reducing pulmonary vascular resistance and lowering the incidence of clinical worsening with probabilities of 86.2% and 79.2%, respectively. Conclusion Analysis revealed positive advantages for the use of PAH-targeted drugs in patients with CTEPH. Overall, treprostinil and riociguat were superior to all other PAH-targeted medications in most of the outcomes investigated.
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Lichtblau M, Berlier C, Saxer S, Carta AF, Mayer L, Groth A, Bader PR, Schneider SR, Furian M, Schwarz EI, Swenson ER, Bloch KE, Ulrich S. Acute Hemodynamic Effect of Acetazolamide in Patients With Pulmonary Hypertension Whilst Breathing Normoxic and Hypoxic Gas: A Randomized Cross-Over Trial. Front Med (Lausanne) 2021; 8:681473. [PMID: 34368187 PMCID: PMC8341560 DOI: 10.3389/fmed.2021.681473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 06/24/2021] [Indexed: 01/30/2023] Open
Abstract
Aims: To test the acute hemodynamic effect of acetazolamide in patients with pulmonary hypertension (PH) under ambient air and hypoxia. Methods: Patients with pulmonary arterial or chronic thromboembolic PH (PAH/CTEPH) undergoing right heart catheterization were included in this randomized, placebo-controlled, double-blinded, crossover trial. The main outcome, pulmonary vascular resistance (PVR), further hemodynamics, blood- and cerebral oxygenation were measured 1 h after intravenous administration of 500 mg acetazolamide or placebo-saline on ambient air (normoxia) and at the end of breathing hypoxic gas (FIO2 0.15, hypoxia) for 15 min. Results: 24 PH-patients, 71% men, mean ± SD age 59 ± 14 years, BMI 28 ± 5 kg/m2, PVR 4.7 ± 2.1 WU participated. Mean PVR after acetazolamide vs. placebo was 5.5 ± 3.0 vs. 5.3 ± 3.0 WU; mean difference (95% CI) 0.2 (−0.2–0.6, p = 0.341). Heart rate was higher after acetazolamide (79 ± 12 vs. 77 ± 11 bpm, p = 0.026), pH was lower (7.40 ± 0.02 vs. 7.42 ± 0.03, p = 0.002) but PaCO2 and PaO2 remained unchanged while cerebral tissue oxygenation increased (71 ± 6 vs. 69 ± 6%, p = 0.017). In acute hypoxia, acetazolamide decreased PVR by 0.4 WU (0.0–0.9, p = 0.046) while PaO2 and PaCO2 were not changed. No adverse effects occurred. Conclusions: In patients with PAH/CTEPH, i.v. acetazolamide did not change pulmonary hemodynamics compared to placebo after 1 hour in normoxia but it reduced PVR after subsequent acute exposure to hypoxia. Our findings in normoxia do not suggest a direct acute pulmonary vasodilator effect of acetazolamide. The reduction of PVR during hypoxia requires further corroboration. Whether acetazolamide improves PH when given over a prolonged period by stimulating ventilation, increasing oxygenation, and/or altering vascular inflammation and remodeling remains to be investigated.
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Affiliation(s)
- Mona Lichtblau
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Charlotte Berlier
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Arcangelo F Carta
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Laura Mayer
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Alexandra Groth
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Patrick R Bader
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Simon R Schneider
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Michael Furian
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Erik R Swenson
- Division of Pulmonary, Critical Care and Sleep Medicine, VA Puget Sound Health Care System, University of Washington, Seattle, WA, United States
| | - Konrad E Bloch
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital Zurich, Zurich, Switzerland
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Kim NH, Papamatheakis DG, Fernandes TM. Evolution of randomized, controlled studies of medical therapy in chronic thromboembolic pulmonary hypertension. Pulm Circ 2021; 11:20458940211007373. [PMID: 34104419 PMCID: PMC8150542 DOI: 10.1177/20458940211007373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 01/09/2021] [Indexed: 12/22/2022] Open
Abstract
Although pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH), many patients have inoperable disease, and some have persistent or recurrent pulmonary hypertension (PH) after surgery. Alternative options (balloon pulmonary angioplasty (BPA) and PH-targeted medical therapy) are, therefore, required. Studies of medical therapies for CTEPH have evolved since Aerosolized Iloprost Randomized (AIR), the first randomized, controlled study of a PH-targeted therapy (inhaled iloprost) to include patients with CTEPH. Key learnings from these studies include the need to evaluate CTEPH separately from other types of PH, the importance of prospective operability adjudication as part of the protocol, and the need for sufficient duration to allow treatment benefits to become apparent. The 16-week Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase-Stimulator Study 1 (CHEST-1) study was the first to operationalize these learnings, demonstrating a significant mean improvement in 6-minute walk distance (+46 m) and improvements in hemodynamic endpoints with riociguat versus placebo. Findings from previous studies will inform the design of future studies to address key issues related to combination medical therapy. Data on combinations of macitentan with phosphodiesterase type 5 inhibitors or oral prostanoids are available from MERIT, the first study to allow such regimens. No data on combinations including riociguat, the only licensed medical therapy for CTEPH, are available. Studies are also needed for multimodality treatment, including medical therapy plus BPA, and medical therapy as a bridge to PEA in selected operable patients. To address these issues and improve patient outcomes, it is vital that we learn from current studies to improve future trial design.
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Affiliation(s)
- Nick H. Kim
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Cattran A, Elwing J. Successful use of intravenous treprostinil as a bridge to pulmonary thromboendarterectomy. BMJ Case Rep 2021; 14:14/3/e235806. [PMID: 33766958 PMCID: PMC8006775 DOI: 10.1136/bcr-2020-235806] [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: 11/03/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) involves non-resolving thromboemboli in the pulmonary arteries. Treatment for CTEPH includes lifelong anticoagulation and determination of patients who have disease which is operable versus inoperable. Pulmonary arterial hypertension (PAH) targeted therapies are oftentimes used as a bridge to pulmonary thromboendarterectomy (PTE), though riociguat is the only Food and Drug Administration (FDA)-approved therapy for CTEPH. There is a paucity of data regarding the efficacy of other PAH therapies, particularly as a bridge to PTE. Here, we present a case report of severe CTEPH related to ventriculoatrial shunt in which intravenous treprostinil was used as a bridge to PTE.
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Affiliation(s)
- Ashley Cattran
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jean Elwing
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by unresolved thrombi in the pulmonary arteries and microvasculopathy in nonoccluded areas. If left untreated, progressive pulmonary hypertension will induce right heart failure and, finally, death. Currently, pulmonary endarterectomy (PEA) remains the only method that has the potential to cure CTEPH. Unfortunately, up to 40% of patients are ineligible for this procedure for various reasons. In recent years, refined balloon pulmonary angioplasty (BPA) has become an alternative option for inoperable CTEPH patients, and it may be another curative treatment in the future, particularly in combination with prior PEA. Nevertheless, 23% of patients still suffer from persistent PH after BPA. Given that CTEPH shares many similarities with idiopathic pulmonary arterial hypertension (PAH), targeted drugs developed for PAH are also attractive options for CTEPH, especially for inoperable or persistent/recurrent CTEPH patients. To date, riociguat, macitentan, and subcutaneous treprostinil are the only drugs proven by randomized control trials to be capable of improving the exercise capacity (6-min walking distance) of CTEPH patients. In this review, we summarize the achievements and unresolved problems of PAH-targeted therapy for CTEPH over the last decade.
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Hoette S, Creuzé N, Rochitte CE, Simonneau G, Humbert M, Souza R, Chemla D. Chronic thromboembolic and pulmonary arterial hypertension share right ventricular and pulmonary artery CMR features. Pulmonology 2019; 25:248-251. [PMID: 31080042 DOI: 10.1016/j.pulmoe.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 03/03/2019] [Accepted: 03/09/2019] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Cardiac magnetic resonance (CMR) imaging has gained importance in pulmonary hypertension (PH) and studies have demonstrated its use as a surrogate marker and in following treatment of these patients. The pathophysiology of PH differs between pulmonary arterial hypertension (PAH, group 1) and chronic thromboembolic PH (CTEPH, group 4). OBJECTIVES The present study tested the hypothesis that PAH and CTEPH display different characteristics on CMR imaging. METHODS 46 patients were evaluated for pulmonary vascular disease in the French National Reference Center for PH (23 PAH and 23 CTEPH matched for age and gender). All patients had the right heart catheterization (RHC) and CMR imaging performed within 48h. CMR imaging was performed on a 1.5 T scanner. RESULTS PAH and CTEPH had similar body surface area and similar invasive hemodynamics, including mean pulmonary arterial pressure, cardiac index, pulmonary vascular resistance and right atrial pressure. PAH and CTEPH had similar CMR data. Right ventricular (RV) morphology and function and pulmonary artery (PA) data were also similar. CONCLUSION Age- and sex-matched PAH and CTEPH patients displayed similar values of the CMR indices of RV and PA morphology and function, suggesting that the RV-PA responses are similar in both groups, mostly related to the overall increase in after load.
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Affiliation(s)
- S Hoette
- Pulmonary Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - N Creuzé
- Physiology and Radiology, Faculté de Médecine Paris 11-APHP, Le Kremlin Bicêtre, France
| | - C E Rochitte
- Cardiovascular Imaging, Heart Institute, University of Sao Paulo Medical School Sao Paulo, Brazil
| | - G Simonneau
- Pneumology-APHP-Paris11 University-Inserm UMR_S999 Le Kremlin Bicêtre, France
| | - M Humbert
- Pneumology-APHP-Paris11 University-Inserm UMR_S999 Le Kremlin Bicêtre, France
| | - R Souza
- Pulmonary Department, Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil.
| | - D Chemla
- Physiology and Radiology, Faculté de Médecine Paris 11-APHP, Le Kremlin Bicêtre, France
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13
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Berlier C, Schwarz EI, Saxer S, Lichtblau M, Ulrich S. Real-Life Experience with Selexipag as an Add-On Therapy to Oral Combination Therapy in Patients with Pulmonary Arterial or Distal Chronic Thromboembolic Pulmonary Hypertension: A Retrospective Analysis. Lung 2019; 197:353-360. [PMID: 30963265 DOI: 10.1007/s00408-019-00222-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 03/25/2019] [Indexed: 12/25/2022]
Abstract
BACKGROUND Patients with pulmonary arterial hypertension (PAH) and distal chronic thromboembolic pulmonary hypertension (CTEPH) who still reveal risk factors of worse prognosis on double combination therapy may benefit from add-on therapy with the novel oral selective prostacyclin receptor agonist selexipag. METHODS We reviewed all patients with PAH/distal CTEPH in the Zurich cohort who received selexipag as add-on to oral combination therapy and retrieved New York Heart Association (NYHA) functional class, 6-min walk distance (6MWD), NT-pro-BNP, quality of life questionnaires (CAMPHOR and EuroQoL), tricuspid pressure gradient (TPG) by echocardiography and cardiopulmonary exercise test parameters (power output and oxygen uptake). RESULTS Twenty-three patients with PAH/CTEPH (20/3), 14 females, median (quartiles) age 56 (46; 66) years received an oral triple therapy containing selexipag at a median dose of 2000 (1600; 3100) mcg during 221 (113; 359) days. The following parameters were stabilized from baseline to last FU: 6MWD (440 (420; 490) to 464 (420; 526) m), NYHA class (three to two), NT-pro-BNP (326 (167; 1725) to 568 (135; 1856) ng/l), TPG, power output, and oxygen uptake. Quality of life reflected by the CAMPHOR and EuroQoL improved. CONCLUSIONS Early initiation of triple oral combination therapy including selexipag in PAH/CTEPH with intermediate risk factor profile may help to stabilize functional class, exercise performance, and pulmonary hemodynamics in a real-life setting and potentially improves quality of life. Whether these beneficial effects can be truly attributed to the addition of selexipag should be addressed in future randomized controlled trials.
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Affiliation(s)
- Charlotte Berlier
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Esther I Schwarz
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Mona Lichtblau
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Zurich, Switzerland. .,Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
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14
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), classified as World Health Organization (WHO) group 4 pulmonary hypertension (PH), is an interesting and rare pulmonary vascular disorder secondary to mechanical obstruction of the pulmonary vasculature from thromboembolism resulting in PH. The pathophysiology is complex, beginning with mechanical obstruction of the pulmonary arteries, which eventually leads to arteriopathic changes and vascular remodeling in the nonoccluded arteries and in the distal segments of the occluded arteries mediated by thrombus nonresolution, abnormal angiogenesis, endothelial dysfunction, and various local growth factors. Based on available data, CTEPH is a rare disease entity occurring in a small proportion (0.5-3%) of patients after acute pulmonary embolism with an annual incidence ranging anywhere between 1 and 7 cases per million population. It is often underdiagnosed or misdiagnosed as idiopathic pulmonary arterial hypertension due to a lack of clinical suspicion or the under-utilization of radionuclide ventilation/perfusion scan. Although the current standard remains planar ventilation/perfusion scintigraphy as the initial imaging study to screen for CTEPH, and invasive pulmonary angiography with right heart catheterization as confirmatory modalities, they are likely to be replaced by modalities that can provide both anatomic and functional data while minimizing radiation exposure. Surgery is the gold standard treatment and offers better improvements in clinical and hemodynamic parameters compared with medical therapy. The management of CTEPH requires a multidisciplinary team, operability assessment, experienced surgical center, and the consideration of medical PH-directed therapies in patients who have inoperable disease, in addition to supportive therapies. Although, balloon pulmonary angioplasty is gaining interest to improve pulmonary hemodynamics and symptoms in CTEPH patients not amenable to surgery, further investigative randomized studies are needed to validate its use. It is very important for the present-day physician to be familiar with the disease entity and its appropriate evaluation to facilitate early diagnosis and appropriate management.
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15
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Groth A, Saxer S, Bader PR, Lichtblau M, Furian M, Schneider SR, Schwarz EI, Bloch KE, Ulrich S. Acute hemodynamic changes by breathing hypoxic and hyperoxic gas mixtures in pulmonary arterial and chronic thromboembolic pulmonary hypertension. Int J Cardiol 2018; 270:262-267. [PMID: 29891241 DOI: 10.1016/j.ijcard.2018.05.127] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Revised: 04/03/2018] [Accepted: 05/30/2018] [Indexed: 01/26/2023]
Abstract
BACKGROUND There is insufficient evidence to counsel patients with pulmonary hypertension undergoing altitude or air travel. We thus aimed to study hemodynamic response of patients with pulmonary arterial or chronic thromboembolic pulmonary hypertension (PAH/CTEPH) during changes in inspiratory oxygen partial pressure. METHODS AND RESULTS Consecutive patients undergoing right heart catheterization had hemodynamic assessments whilst breathing ambient air (normoxia, FiO2 0.21, at altitude 490 m), nitrogen-enriched air (hypoxia, FiO2 0.16, simulated altitude 2600 m) and oxygen (hyperoxia, FiO2 1.0), each for 10 min. Data from patients with PAH/CTEPH with mean pulmonary artery pressure (mPAP) ≥25 mmHg, pulmonary artery wedge pressure ≤15 mmHg, were compared to data from controls, mPAP <20 mmHg. 28 PAH/CTEPH-patients, 15 women, median age (quartiles) 62y (49;73), mPAP 35 mmHg (31;44), PaO2 7.1 kPa (6.8;9.3) and 16 controls, 12 women, 60y (52;69), mPAP 18 mmHg (16;18), PaO2 9.5 kPa (8.5;10.6) were included. Hypoxia reduced the PaO2 in PAH/CTEPH-patients by median of 2.3 kPa, in controls by 3.3 kPa, difference (95%CI) in change 1.0 (0.02 to 1.9), p < 0.05. Corresponding changes in pulmonary vascular resistance, mPAP and cardiac output were nonsignificant in both groups. Hyperoxia decreased mPAP in PAH/CTEPH-patients by 4 mmHg (2 to 6), in controls by 2 mmHg (0 to 3), difference in change 3 mmHg (0 to 5), p < 0.05. CONCLUSIONS In patients with PAH/CTEPH, very short-term exposure to moderate hypoxia similar to 2600 m altitude or during commercial air travel did not deteriorate hemodynamics. These results encourage studying the response of PAH/CTEPH during daytrips to the mountain or air travel.
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Affiliation(s)
- Alexandra Groth
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Stéphanie Saxer
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Patrick R Bader
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Mona Lichtblau
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Michael Furian
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | | | - Esther I Schwarz
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Konrad E Bloch
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland
| | - Silvia Ulrich
- Clinic of Pulmonology, University Hospital of Zurich, Switzerland.
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16
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Bartenstein P, Saxer S, Appenzeller P, Lichtblau M, Schwarz EI, Ulrich S. Risk Factor Profiles Achieved with Medical Therapy in Prevalent Patients with Pulmonary Arterial and Distal Chronic Thromboembolic Pulmonary Hypertension. Respiration 2018; 96:127-137. [PMID: 29642071 DOI: 10.1159/000488000] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 02/26/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The latest pulmonary hypertension (PH) guidelines define therapeutic goals in terms of symptoms, exercise capacity, and haemodynamics for patients with pulmonary arterial hypertension (PAH) and recommend advanced combined medical therapy. For inoperable or post-surgical residual distal chronic thromboembolic PH (CTEPH) medical treatment is similarly advised. OBJECTIVES We analysed whether risk factor goals are achieved and combination therapy is used in prevalent patients with PAH or distal CTEPH. METHODS PAH or distal CTEPH patients who were seen at the University Hospital Zurich during the last year were analysed in terms of demography, clinical data, medication, and therapeutic goals. Achievement of therapeutic goals was defined as New York Heart Association (NYHA) class ≤II, N-terminal pro-brain natriuretic peptide (NTpro-BNP) < 300 ng/L, and 6-min walking distance (6MWD) > 440 m. RESULTS A total of 108 PAH patients (age 59 ± 18 years, 62% female, 64% idiopathic, 36% associated) and 38 distal CTEPH patients (age 69 ± 14 years, 55% female) were included. They had been diagnosed on average 66 ± 48 months (±SD) previously. The percentage of PAH/CTEPH patients with NYHA ≤II was 52/53, respectfully, the percentage of those with NTproBNP < 300 ng/L was 61/52, and with 6MWD > 440 m 63/50. Overall, 33/31% fulfilled 3 and 29/35% fulfilled 2 of these goals. Regarding therapy, 43% of PAH patients were on double and 10% on triple combination therapy, whereas 16% of distal CTEPH patients were on double and 3% on triple combination therapy. CONCLUSIONS In this real-life cohort of prevalent patients with PAH or distal CTEPH, targeted drug therapy resulted in an achievement of ≥2/3 predefined therapeutic goals in 2/3 of patients. Patients with PAH were more likely to receive combination therapy compared to CTEPH patients.
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17
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Abstract
Venous thromboembolism (VTE) is a common disease (~700 per 100 000) that is associated with significant risk of recurrence, chronic complications, and substantial mortality, with reported death rates of up to 40% at 10 years. The development of novel anticoagulants has revolutionized the treatment of acute VTE, while strategies for prevention and treatment of chronic complications still seek for such a landmark change. Impaired thrombus resolution is the common denominator behind VTE complications, which are postthrombotic syndrome (PTS) and chronic thromboembolic pulmonary hypertension (CTEPH). PTS and CTEPH are associated with substantial morbidity and high healthcare expenses. While PTS occurs in up to 50% of patients after symptomatic deep vein thrombosis, only a small and poorly defined number of patients are diagnosed with CTEPH after pulmonary embolism. This review is a comprehensive summary of VTE-related chronic complications, their epidemiology, diagnosis, and treatment.
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Affiliation(s)
- M-P Winter
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - G H Schernthaner
- Division of Angiology, Medical University of Vienna, Vienna, Austria
| | - I M Lang
- Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
- Division of Cardiology, Medical University of Vienna, Vienna, Austria
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18
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Xu QX, Yang YH, Geng J, Zhai ZG, Gong JN, Li JF, Tang X, Wang C. Clinical Study of Acute Vasoreactivity Testing in Patients with Chronic Thromboembolic Pulmonary Hypertension. Chin Med J (Engl) 2017; 130:382-391. [PMID: 28218209 PMCID: PMC5324372 DOI: 10.4103/0366-6999.199829] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND The clinical significance of acute vasoreactivity testing (AVT) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) remains unclear. We analyzed changes in hemodynamics and oxygenation dynamics indices after AVT in patients with CTEPH using patients with pulmonary arterial hypertension (PAH) as controls. METHODS We analyzed retrospectively the results of AVT in 80 patients with PAH and 175 patients with CTEPH registered in the research database of Beijing Chao-Yang Hospital between October 2005 and August 2014. Demographic variables, cardiopulmonary indicators, and laboratory findings were compared in these two subgroups. A long-term follow-up was conducted in patients with CTEPH. Between-group comparisons were performed using the independent-sample t-test or the rank sum test, within-group comparisons were conducted using the paired t-test or the Wilcoxon signed-rank test, and count data were analyzed using the Chi-squared test. Survival was estimated using the Kaplan-Meier method and log-rank test. RESULTS The rates of positive response to AVT were similar in the CTEPH (25/175, 14.3%) and PAH (9/80, 11.3%) groups (P > 0.05). Factors significantly associated a positive response to AVT in the CTEPH group were level of N-terminal pro-brain natriuretic peptide (≤1131.000 ng/L), mean pulmonary arterial pressure (mPAP, ≤44.500 mmHg), pulmonary vascular resistance (PVR, ≤846.500 dyn·s-1·m-5), cardiac output (CO, ≥3.475 L/min), and mixed venous oxygen partial pressure (PvO2, ≥35.150 mmHg). Inhalation of iloprost resulted in similar changes in mean blood pressure, mPAP, PVR, systemic vascular resistance, CO, arterial oxygen saturation (SaO2), mixed venous oxygen saturation, partial pressure of oxygen in arterial blood (PaO2), PvO2, and intrapulmonary shunt (Qs/Qt) in the PAH and CTEPH groups (all P > 0.05). The survival time in patients with CTEPH with a negative response to AVT was somewhat shorter than that in AVT-responders although the difference was not statistically significant (χ2 =3.613, P = 0.057). The survival time of patients with CTEPH who received calcium channel blockers (CCBs) was longer than that in the group with only basic treatment and not shorter than that of patients who receiving targeted drugs or underwent pulmonary endarterectomy (PEA) although there was no significant difference between the four different treatment regimens (χ2 =3.069, P = 0.381). CONCLUSIONS The rates of positive response to AVT were similar in the CTEPH and PAH groups, and iloprost inhalation induced similar changes in hemodynamics and oxygenation dynamics indices. A positive response to AVT in the CTEPH group was significantly correlated with milder disease and better survival. Patients with CTEPH who cannot undergo PEA or receive targeted therapy but have a positive response to AVT might benefit from CCB treatment.
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Affiliation(s)
- Qi-Xia Xu
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020; Department of Respiratory Medicine, Capital Medical University, Beijing 100069; Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China
| | - Yuan-Hua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Jie Geng
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Bengbu Medical College, Bengbu, Anhui 233004, China
| | - Zhen-Guo Zhai
- Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029, China
| | - Juan-Ni Gong
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Ji-Feng Li
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Xiao Tang
- Department of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing Chao-Yang Hospital, Capital Medical University, Beijing 100020, China
| | - Chen Wang
- Department of Respiratory Medicine, Capital Medical University, Beijing 100069; Department of Respiratory and Critical Care Medicine, China-Japan Friendship Hospital, Beijing 100029; National Clinical Research Center for Respiratory Diseases, Beijing 100730, China
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20
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Hoeper MM. Pharmacological therapy for patients with chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2016; 24:272-82. [PMID: 26028639 PMCID: PMC9487825 DOI: 10.1183/16000617.00001015] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but life-threatening disease resulting from unresolved thromboembolic obstructions. Pulmonary endarterectomy (PEA) surgery is the gold-standard treatment as it is potentially curative; however, not all patients are deemed operable and up to one-third have persistent or recurrent CTEPH after the procedure. Pulmonary arterial hypertension (PAH) and CTEPH have similar clinical presentations and histopathological features, so agents shown to be effective in PAH have often been prescribed to patients with CTEPH in the absence of proven therapies. However, clinical evidence for this strategy is not compelling. A number of small uncontrolled trials have investigated endothelin receptor antagonists, prostacyclin analogues and phosphodiesterase type 5 inhibitors in CTEPH with mixed results, and a phase III study of the endothelin receptor antagonist bosentan met only one of its two co-primary end-points. Recently, however, the soluble guanylate cyclase stimulator, riociguat, was approved in the USA and Europe for the treatment of inoperable or persistent/recurrent CTEPH following positive results from the phase III CHEST study (Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase–Stimulator Trial). This article reviews the current evidence for the use of pharmacological therapies in CTEPH. A review of pharmacological treatment of inoperable or persistent/recurrent CTEPH and the future standard of carehttp://ow.ly/KMUQV
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Affiliation(s)
- Marius M Hoeper
- Dept of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research (DZL), Hannover, Germany
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21
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Hasler ED, Müller-Mottet S, Furian M, Saxer S, Huber LC, Maggiorini M, Speich R, Bloch KE, Ulrich S. Pressure-Flow During Exercise Catheterization Predicts Survival in Pulmonary Hypertension. Chest 2016; 150:57-67. [PMID: 26892603 DOI: 10.1016/j.chest.2016.02.634] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/04/2016] [Accepted: 02/02/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Pulmonary hypertension manifests with impaired exercise capacity. Our aim was to investigate whether the mean pulmonary arterial pressure to cardiac output relationship (mPAP/CO) predicts transplant-free survival in patients with pulmonary arterial hypertension (PAH) and inoperable chronic thromboembolic pulmonary hypertension (CTEPH). METHODS Hemodynamic data according to right heart catheterization in patients with PAH and CTEPH at rest and during supine incremental cycle exercise were analyzed. Transplant-free survival and predictive value of hemodynamics were assessed by using Kaplan-Meier and Cox regression analyses. RESULTS Seventy patients (43 female; 54 with PAH, 16 with CTEPH; median (quartiles) age, 65 [50; 73] years; mPAP, 34 [29; 44] mm Hg; cardiac index, 2.8 [2.3; 3.5] [L/min]/m(2)) were followed up for 610 (251; 1256) days. Survival at 1, 3, 5, and 7 years was 89%, 81%, 71%, and 59%. Age, World Health Organization-functional class, 6-min walk test, and mixed-venous oxygen saturation (but not resting hemodynamics) predicted transplant-free survival. Maximal workload (hazard ratio [HR], 0.94 [95% CI, 0.89-0.99]; P = .027), peak cardiac index (HR, 0.51 [95% CI, 0.27-0.95]; P = .034), change in cardiac index, 0.25 [95% CI, 0.06-0.94]; P = .040), and mPAP/CO (HR, 1.02 [95% CI, 1.01-1.03]; P = .003) during exercise predicted survival. Values for mPAP/CO predicted 3-year transplant-free survival with an area under the curve of 0.802 (95% CI, 0.66-0.95; P = .004). CONCLUSIONS In this collective of patients with PAH or CTEPH, the pressure-flow relationship during exercise predicted transplant-free survival and correlated with established markers of disease severity and outcome. Right heart catheterization during exercise may provide important complementary prognostic information in the management of pulmonary hypertension.
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Affiliation(s)
| | | | - Michael Furian
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Stéphanie Saxer
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Lars C Huber
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Marco Maggiorini
- Clinic of Critical Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Rudolf Speich
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland
| | - Konrad E Bloch
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland; Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Pulmonary Clinic, University Hospital Zurich, Zurich, Switzerland; Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland.
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22
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Hadinnapola C, Pepke-Zaba J. Developments in pulmonary arterial hypertension-targeted therapy for chronic thromboembolic pulmonary hypertension. Expert Rev Respir Med 2015; 9:559-69. [PMID: 26366805 DOI: 10.1586/17476348.2015.1085805] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterised by the presence of organised chronic thromboembolic material occluding the proximal pulmonary arteries and a vasculopathy in the distal pulmonary arterial tree. Pulmonary endarterectomy (PEA) is a potential cure for many patients with CTEPH. However, PEA is not suitable for patients with a significant distal distribution of chronic thromboembolic material or with significant comorbidities. Also, a proportion of patients are left with residual CTEPH post PEA. Until recently, pulmonary arterial hypertension-targeted therapies have been used off licence to treat patients with inoperable or residual CTEPH. The CHEST1 study investigated the use of riociguat and was the first randomised controlled trial to show efficacy in inoperable or residual CTEPH. In this review, we explore the pathophysiology of CTEPH and review the current trial evidence for pulmonary arterial hypertension-targeted therapies. We also include a discussion of physiological considerations that require further investigation.
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Affiliation(s)
- Charaka Hadinnapola
- a Pulmonary Vascular Diseases Unit, Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
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23
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Claessen G, La Gerche A, Wielandts JY, Bogaert J, Van Cleemput J, Wuyts W, Claus P, Delcroix M, Heidbuchel H. Exercise pathophysiology and sildenafil effects in chronic thromboembolic pulmonary hypertension. Heart 2015; 101:637-44. [PMID: 25686630 DOI: 10.1136/heartjnl-2014-306851] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Symptoms in patients with chronic thromboembolic pulmonary hypertension (CTEPH) predominantly occur during exercise, while haemodynamic assessment is generally performed at rest. We hypothesised that exercise imaging of RV function would better explain exercise limitation and the acute effects of pulmonary vasodilator administration than resting measurements. METHODS Fourteen patients with CTEPH and seven healthy control subjects underwent cardiopulmonary testing to determine peak exercise oxygen consumption (VO2peak) and ventilatory equivalent for carbon dioxide (VE/VCO2) at the anaerobic threshold. Subsequently, cardiac MRI was performed at rest and during supine bicycle exercise with simultaneous invasive measurement of mean pulmonary arterial pressure (mPAP) before and after sildenafil. RESULTS During exercise, patients with CTEPH had a greater increase in the ratio of mPAP relative to cardiac output (CO) than controls (6.7 (5.1-8.7) vs 0.94 (0.86-1.8) mm Hg/L/min; p < 0.001). Stroke volume index (SVi) and RVEF increased during exercise in controls, but not in patients with CTEPH (interaction p < 0.001). Sildenafil decreased the mPAP/CO slope and increased SVi and RVEF in patients with CTEPH (p < 0.05) but not in controls. In patients with CTEPH, RVEF reserve correlated moderately with VO2peak (r = 0.60; p = 0.030) and VE/VCO2 (r = -0.67; p = 0.012). By contrast, neither VO2peak nor VE/VCO2 correlated with resting RVEF. CONCLUSIONS Exercise measures of RV function explain much of the variance in the exercise capacity of patients with CTEPH while resting measures do not. Sildenafil increases SVi during exercise in patients with CTEPH, but not in healthy subjects.
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Affiliation(s)
- Guido Claessen
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium University Hospitals Leuven, Leuven, Belgium
| | - Andre La Gerche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Jean-Yves Wielandts
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium University Hospitals Leuven, Leuven, Belgium
| | - Jan Bogaert
- University Hospitals Leuven, Leuven, Belgium Department of Imaging & Pathology, University of Leuven, Leuven, Belgium
| | - Johan Van Cleemput
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium University Hospitals Leuven, Leuven, Belgium
| | - Wim Wuyts
- University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Piet Claus
- Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Marion Delcroix
- University Hospitals Leuven, Leuven, Belgium Department of Clinical and Experimental Medicine, University of Leuven, Leuven, Belgium
| | - Hein Heidbuchel
- University of Hasselt and Heart Center, Jessa Hospital, Hasselt, Belgium
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Mueller-Mottet S, Stricker H, Domeninghetti G, Azzola A, Geiser T, Schwerzmann M, Weilenmann D, Schoch O, Fellrath JM, Rochat T, Lador F, Beghetti M, Nicod L, Aubert JD, Popov V, Speich R, Keusch S, Hasler E, Huber LC, Grendelmeier P, Tamm M, Ulrich S. Long-Term Data from the Swiss Pulmonary Hypertension Registry. Respiration 2015; 89:127-40. [DOI: 10.1159/000370125] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 11/21/2014] [Indexed: 11/19/2022] Open
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Idrees MM, Saleemi S, Azem MA, Aldammas S, Alhazmi M, Khan J, Gari A, Aldabbagh M, Sakkijha H, Aldalaan A, Alnajashi K, Alhabeeb W, Nizami I, Kouatli A, Chehab M, Tamimi O, Banjar H, Kashour T, Lopes A, Minai O, Hassoun P, Pasha Q, Mayer E, Butrous G, Bhagavathula S, Ghio S, Swiston J, Boueiz A, Tonelli A, Levy RD, Hoeper M, Levy RD. Saudi guidelines on the diagnosis and treatment of pulmonary hypertension: 2014 updates. Ann Thorac Med 2014; 9:S1-S15. [PMID: 25076987 PMCID: PMC4114283 DOI: 10.4103/1817-1737.134006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 04/05/2014] [Indexed: 11/26/2022] Open
Abstract
The Saudi Association for Pulmonary Hypertension (previously called Saudi Advisory Group for Pulmonary Hypertension) has published the first Saudi Guidelines on Diagnosis and Treatment of Pulmonary Arterial Hypertension back in 2008.[1] That guideline was very detailed and extensive and reviewed most aspects of pulmonary hypertension (PH). One of the disadvantages of such detailed guidelines is the difficulty that some of the readers who just want to get a quick guidance or looking for a specific piece of information might face. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and helpful to clinicians dealing with PH patients to select the best management strategies for the typical patient suffering from a specific condition. This Guideline was designed to provide recommendations for problems frequently encountered by practicing clinicians involved in management of PH. This publication targets mainly adult and pediatric PH-treating physicians, but can also be used by other physicians interested in PH.
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Affiliation(s)
- Majdy M Idrees
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sarfraz Saleemi
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - M Ali Azem
- Department of Critical Care Medicine, King Fahd Medical Center, Dammam, Saudi Arabia
| | - Saleh Aldammas
- Department of Pulmonary Medicine, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Manal Alhazmi
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Javid Khan
- Department of Pulmonary Medicine, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdulgafour Gari
- Department of Pulmonary Medicine, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Maha Aldabbagh
- Department of Pediatric, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Husam Sakkijha
- Department of Pulmonary and Critical Care Medicine, King Fahd Medical City, Riyadh, Saudi Arabia
| | - Abdulla Aldalaan
- Department of Pulmonary Medicine, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Khalid Alnajashi
- Department of Congenital Heart Disease, Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Waleed Alhabeeb
- Department of Cardiology, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Imran Nizami
- Department of Organ Transplant, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Amjad Kouatli
- Department of Pediatric Cardiology, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - May Chehab
- Department of Pediatric Intensive Care, Price Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Omar Tamimi
- Department of Pediatric Cardiology, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hanaa Banjar
- Department of Pediatric, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Tarek Kashour
- Department of Cardiac Science, King Khalid University Hospital, Riyadh, Saudi Arabia
| | - Antonio Lopes
- Department of Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Omar Minai
- Respiratory Institute, Cleveland Clinic, Ohio, USA
| | - Paul Hassoun
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | - Qadar Pasha
- Department of CSIR-Institute of Genomics and Integrative Biology, Delhi, India
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Ghazwan Butrous
- Department of Cardiopulmonary science, Imperial College, London, UK
| | | | - Stefano Ghio
- Department of Fondazione IR IRCCS Policlinico San Matteo, Pavia, Italy
| | - John Swiston
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Adel Boueiz
- Pulmonary Hypertension Program, Johns Hopkins University, Baltimore, Maryland, USA
| | | | - Robert D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Marius Hoeper
- Department of Pulmonary Hypertension Program, Hanover Medical School, Hanover, Germany
| | - Rober D Levy
- Department of Pulmonary Medicine, University of British Columbia, Vancouver, BC, Canada
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Abstract
Pulmonary hypertension, an elevation of the mean pulmonary artery pressure ≥25 mmHg, ultimately leads to premature death due to right ventricular dysfunction. Ten treatments from three classes of drugs are licensed for the management of pulmonary arterial hypertension. These treatments have improved exercise capacity but median survival is still poor. Additionally there are no licensed therapies for the other groups of pulmonary hypertension. Riociguat is a novel drug that stimulates soluble guanylate cyclase independently of nitric oxide and in synergy with nitric oxide. This review summarises the available evidence for riociguat in the treatment across all groups of pulmonary hypertension with a focus on pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- John E Cannon
- Pulmonary Vascular Disease Unit, Papworth Hospital, Papworth Everard, Cambridge, CB23 3RE, UK
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Abstract
Diseases of the pulmonary vasculature are a cause of increased pulmonary vascular resistance (PVR) in pulmonary embolism, chronic thromboembolic pulmonary hypertension (CTEPH), and pulmonary arterial hypertension or decreased PVR in pulmonary arteriovenous malformations on hereditary hemorrhagic telangiectasia, portal hypertension, or cavopulmonary anastomosis. All these conditions are associated with a decrease in both arterial PO2 and PCO2. Gas exchange in pulmonary vascular diseases with increased PVR is characterized by a shift of ventilation and perfusion to high ventilation-perfusion ratios, a mild to moderate increase in perfusion to low ventilation-perfusion ratios, and an increased physiologic dead space. Hypoxemia in these patients is essentially explained by altered ventilation-perfusion matching amplified by a decreased mixed venous PO2 caused by a low cardiac output. Hypocapnia is accounted for by hyperventilation, which is essentially related to an increased chemosensitivity. A cardiac shunt on a patent foramen ovale may be a cause of severe hypoxemia in a proportion of patients with pulmonary hypertension and an increase in right atrial pressure. Gas exchange in pulmonary arteriovenous malformations is characterized by variable degree of pulmonary shunting and/or diffusion-perfusion imbalance. Hypocapnia is caused by an increased ventilation in relation to an increased pulmonary blood flow with direct peripheral chemoreceptor stimulation by shunted mixed venous blood flow.
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Affiliation(s)
- C Mélot
- Department of Emergency Medicine, Erasme University Hospital, Brussels, Belgium.
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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Inami T, Kataoka M, Shimura N, Ishiguro H, Yanagisawa R, Taguchi H, Fukuda K, Yoshino H, Satoh T. Pulmonary edema predictive scoring index (PEPSI), a new index to predict risk of reperfusion pulmonary edema and improvement of hemodynamics in percutaneous transluminal pulmonary angioplasty. JACC Cardiovasc Interv 2013; 6:725-36. [PMID: 23769649 DOI: 10.1016/j.jcin.2013.03.009] [Citation(s) in RCA: 133] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Revised: 03/06/2013] [Accepted: 03/14/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study sought to identify useful predictors for hemodynamic improvement and risk of reperfusion pulmonary edema (RPE), a major complication of this procedure. BACKGROUND Percutaneous transluminal pulmonary angioplasty (PTPA) has been reported to be effective for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). PTPA has not been widespread because RPE has not been well predicted. METHODS We included 140 consecutive procedures in 54 patients with CTEPH. The flow appearance of the target vessels was graded into 4 groups (Pulmonary Flow Grade), and we proposed PEPSI (Pulmonary Edema Predictive Scoring Index) = (sum total change of Pulmonary Flow Grade scores) × (baseline pulmonary vascular resistance). Correlations between occurrence of RPE and 11 variables, including hemodynamic parameters, number of target vessels, and PEPSI, were analyzed. RESULTS Hemodynamic parameters significantly improved after median observation period of 6.4 months, and the sum total changes in Pulmonary Flow Grade scores were significantly correlated with the improvement in hemodynamics. Multivariate analysis revealed that PEPSI was the strongest factor correlated with the occurrence of RPE (p < 0.0001). Receiver-operating characteristic curve analysis demonstrated PEPSI to be a useful marker of the risk of RPE (cutoff value 35.4, negative predictive value 92.3%). CONCLUSIONS Pulmonary Flow Grade score is useful in determining therapeutic efficacy, and PEPSI is highly supportive to reduce the risk of RPE after PTPA. Using these 2 indexes, PTPA could become a safe and common therapeutic strategy for CTEPH.
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Affiliation(s)
- Takumi Inami
- Division of Cardiology, Second Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
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31
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Gabriel Botella F, Labiós Gómez M, Corella Piquer D. [Chronic thromboembolic pulmonary hypertension]. Med Clin (Barc) 2012; 139:215-20. [PMID: 22565100 DOI: 10.1016/j.medcli.2012.02.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 02/13/2012] [Accepted: 02/23/2012] [Indexed: 11/16/2022]
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Duffels MGJ, van der Plas MN, Surie S, Winter MM, Bouma B, Groenink M, van Dijk APJ, Hoendermis E, Berger RMF, Bresser P, Mulder BJM. Bosentan in pulmonary arterial hypertension: a comparison between congenital heart disease and chronic pulmonary embolism. Neth Heart J 2011; 17:334-8. [PMID: 19949475 DOI: 10.1007/bf03086279] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background. In patients with pulmonary hypertension, it is unknown whether the treatment effect of bosentan is dependent on the duration of pulmonary vessel changes. Therefore, we studied the response to bosentan in patients with life-long pulmonary vessel changes (pulmonary arterial hypertension (PAH) due to congenital heart disease (CHD)) and in patients with subacutely induced pulmonary vessel changes (chronic thromboembolic pulmonary hypertension (CTEPH)).Methods. In this open-label study, 18 patients with PAH due to CHD and 16 patients with CTEPH were treated with bosentan for at least one year. All patients were evaluated at baseline and during follow-up by means of the six-minute walk distance (6-MWD) and laboratory tests.Results. Improvement of 6-MWD was comparable in patients with PAH due to CHD (444+/-112 m to 471+/-100 m, p=0.02), and in CTEPH (376+/-152 m to 423+/-141 m, p=0.03) after three months of treatment. After this improvement, 6-MWD stabilised in both groups.Conclusion. Although duration of pulmonary vessel changes is strikingly different in patients with PAH due to CHD and CTEPH, the effect of one year of bosentan treatment was comparable. The main treatment effect appears to be disease stabilisation and decreasing the rate of deterioration. (Neth Heart J 2009;17:334-8.).
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Affiliation(s)
- M G J Duffels
- Department of Cardiology, Academic Medical Center, Amsterdam, the Netherlands
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33
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Affiliation(s)
- Gregory Piazza
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, USA
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34
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Krasuski RA, Devendra GP, Hart SA, Wang A, Harrison JK, Bashore TM. Response to inhaled nitric oxide predicts survival in patients with pulmonary hypertension. J Card Fail 2011; 17:265-71. [PMID: 21440863 DOI: 10.1016/j.cardfail.2010.11.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 11/18/2010] [Accepted: 11/22/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To examine the ability of vasodilator response to predict survival in a diverse cohort of patients with pulmonary hypertension (PH). PATIENTS & METHODS A total of 214 consecutive treatment-naive patients referred for invasive PH evaluation were enrolled between November 1998 and December 2008. Vasoreactivity was assessed during inhalation of 40 parts per million nitric oxide (iNO) and vasodilator responders were defined as those participants who achieved a mean pulmonary artery pressure (PAP) of ≤ 40 mm Hg and a drop in mean PAP ≥ the median for the cohort (13%). Kaplan-Meier analysis and Cox proportional hazards modeling were used to identify predictors of survival. RESULTS There were 51 deaths (25.9%) over a mean follow-up period of 2.3 years. Kaplan-Meier analysis demonstrated that vasodilator responders had significantly improved survival (P < .01). Vasodilator responders had improved survival regardless of whether or not they had idiopathic or nonidiopathic PH (P = .02, P < .01) or whether or not they had Dana Point class 1 or non-Dana Point class 1 PH (P < .01, P = .01). In multivariate modeling, advanced age, elevated right atrial pressure, elevated serum creatinine, and worsened functional class significantly predicted shorter survival (P = .01, P = .01, P = .01, P < .01), whereas vasodilator response predicted improved survival (P = .01). CONCLUSIONS Vasodilator responsiveness to iNO is an important method of risk stratifying PH patients, with results that apply regardless of clinical etiology.
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Affiliation(s)
- Richard A Krasuski
- Adult Congenital Heart Disease Service, Division of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195, USA.
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Schiess R, Senn O, Fischler M, Huber LC, Vatandaslar S, Speich R, Ulrich S. Tobacco Smoke: A Risk Factor for Pulmonary Arterial Hypertension? Chest 2010; 138:1086-92. [DOI: 10.1378/chest.09-2962] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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36
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Toshner MR, Gopalan D, Suntharalingam J, Treacy C, Soon E, Sheares KK, Morrell NW, Screaton N, Pepke-Zaba J. Pulmonary arterial size and response to sildenafil in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2010; 29:610-5. [PMID: 20227301 PMCID: PMC2954311 DOI: 10.1016/j.healun.2009.12.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2009] [Revised: 12/07/2009] [Accepted: 12/15/2009] [Indexed: 11/25/2022] Open
Abstract
Background Relative area change (RAC) of the proximal pulmonary artery is a measurement of pulmonary artery distensibility and has been shown to correlate with vasoreactivity studies in patients with idiopathic pulmonary arterial hypertension. We have previously noted a relationship between invasive hemodynamic vasoreactivity testing and long-term response to sildenafil in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). We therefore set out to determine whether RAC can provide useful correlatory non-invasive data. Methods Patients recruited to a randomized, controlled trial (RCT) of sildenafil at 40 mg 3 times daily underwent additional magnetic resonance imaging (MRI) at the baseline of the trial. Eighteen patients had an MRI that led to a diagnosis of inoperable distal CTEPH or significant residual CTEPH post-operatively. The primary end-point was improvement in 6-minute walk test (6MWT) with secondary end-points of right heart catheterization–based hemodynamics, N-terminal pro–brain natriuretic peptide (NT pro-BNP) and functional class. RAC assessed by MRI was correlated with trial end-points. Results Fourteen subjects with baseline MRI completed the protocol. RAC was the only baseline variable that correlated at 1 year to the primary end-point of improvement in 6MWT (r = 0.7, p = 0.006), and also to a change in NT pro-BNP (r = 0.59, p = 0.03). Using a cut-off of RAC over 20% there was an 87.5% sensitivity (95% confidence interval [CI]: 45% to 100%) and a 66.7% specificity (95% CI: 22% to 96%) for an improvement in 6MWT of >40 meters. Conclusions RAC correlates with functional response to sildenafil, as measured by the 6MWT, and improved heart function, as measured by NT pro-BNP. RAC shows potential in understanding and possibly predicting treatment response.
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Affiliation(s)
- Mark R Toshner
- Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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37
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Terra-Filho M, Mello MF, Lapa MS, Teixeira RHOB, Jatene FB. Clinical and haemodynamic evaluation of chronic thromboembolic pulmonary hypertension patients scheduled for pulmonary thromboendarterectomy: Is schistosomiasis hypertension an important confounding factor? Clinics (Sao Paulo) 2010; 65:1155-60. [PMID: 21243290 PMCID: PMC2999713 DOI: 10.1590/s1807-59322010001100018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 08/26/2010] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension is a disease affecting approximately 4,000 people per year in the United States. The incidence rate in Brazil, however, is unknown. The estimated survival for patients with chronic thromboembolic pulmonary hypertension without treatment is approximately three years. Pulmonary thromboendarterectomy for select patients is a potentially curative procedure when correctly applied. In Brazil, the clinical and hemodynamic profiles of chronic thromboembolic pulmonary hypertension patients have yet to be described. OBJECTIVES To evaluate the clinical and hemodynamic characteristics of chronic thromboembolic pulmonary hypertension patients scheduled for pulmonary thromboendarterectomy in a referral center for chronic thromboembolic pulmonary hypertension treatment in Brazil. METHODS From December 2006 to November 2009, patients were evaluated and scheduled for pulmonary thromboendarterectomy. The subjects were classified according to gender, age and functional class and were tested for thrombofilia and brain natriuretic peptide levels. RESULTS Thirty-five consecutive chronic thromboembolic pulmonary hypertension patients were evaluated. Two patients tested positive for schistosomiasis, and 31 were enrolled in the study (19 female, 12 male). The majority of patients were categorized in functional classes III and IV. Hemodynamic data showed a mean pulmonary vascular resistance (PVR) of 970.8 ± 494.36 dynas·s·cm-5 and a low cardiac output of 3.378 ± 1.13 L/min. Linear regression revealed a direct relation between cardiac output and pulmonary vascular resistance. Paradoxical septal movement was strongly correlated with pulmonary vascular resistance and cardiac output (p=0.001). Brain natriuretic peptide serum levels were elevated in 19 of 27 patients. CONCLUSIONS In a referral center for pulmonary hypertension in Brazil, chronic thromboembolic pulmonary hypertension patients evaluated for pulmonary thromboendarterectomy had a hemodynamically severe status and had elevated brain natriuretic peptide serum levels. There was a predominance of females in our cohort, and the prevalence of hematological disorders and schistosomiasis was low (less than 10%).
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Affiliation(s)
- Mario Terra-Filho
- Instituto do Coração, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.
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Ewert R, Schäper C, Halank M, Gläser S, Opitz CF. Inhalative iloprost – pharmacology and clinical application. Expert Opin Pharmacother 2009; 10:2195-207. [DOI: 10.1517/14656560903164228] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Krug S, Sablotzki A, Hammerschmidt S, Wirtz H, Seyfarth HJ. Inhaled iloprost for the control of pulmonary hypertension. Vasc Health Risk Manag 2009; 5:465-74. [PMID: 19475782 PMCID: PMC2686263 DOI: 10.2147/vhrm.s3223] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Pulmonary arterial hypertension (PAH) is a life-threatening disease characterized by an elevated pulmonary arterial pressure and vascular resistance with a poor prognosis. Various pulmonary and extrapulmonary causes are now recognized to exist separately from the idiopathic form of pulmonary hypertension. An imbalance in the presence of vasoconstrictors and vasodilators plays an important role in the pathophysiology of the disease, one example being the lack of prostacyclin. Prostacyclin and its analogues are potent vasodilators with antithrombotic, antiproliferative and anti-inflammatory qualities, all of which are important factors in the pathogenesis of precapillary pulmonary hypertension. Iloprost is a stable prostacyclin analogue available for intravenous and aerosolized application. Due to the severe side effects of intravenous administration, the use of inhaled iloprost has become a mainstay in PAH therapy. However, owing to the necessity for 6 to 9 inhalations a day, oral treatment is often preferred as a first-line therapy. Numerous studies proving the efficacy and safety of inhaled iloprost have been performed. It is therefore available for a first-line therapy for PAH. The combination with endothelin-receptor antagonists or sildenafil has shown encouraging effects. Further studies with larger patient populations will have to demonstrate the use of combination therapy for long-term treatment of pulmonary hypertension.
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Affiliation(s)
- Sabine Krug
- Department of Respiratory Medicine, University of Leipzig, Leipzig, Germany.
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Skoro-Sajer N, Hack N, Sadushi-Koliçi R, Bonderman D, Jakowitsch J, Klepetko W, Hoda MAR, Kneussl MP, Fedullo P, Lang IM. Pulmonary Vascular Reactivity and Prognosis in Patients With Chronic Thromboembolic Pulmonary Hypertension. Circulation 2009; 119:298-305. [DOI: 10.1161/circulationaha.108.794610] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background—
Surgical pulmonary endarterectomy is the preferred treatment for chronic thromboembolic pulmonary hypertension. Persistent pulmonary hypertension after pulmonary endarterectomy has been recognized as a major determinant of poor outcome. We tested whether acute vasoreactivity identifies chronic thromboembolic pulmonary hypertension patients prone to develop persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and whether the degree of acute vasoreactivity affects survival or freedom from lung transplantation.
Methods and Results—
Right-sided heart catheterization at baseline and after inhalation of 40 ppm nitric oxide for 20 minutes was performed in 103 patients (56.3±15.3 years old, 53 women). Reductions in mean pulmonary arterial pressure (ΔmPAP; −8.8±12.6%;
P
<0.0001) and pulmonary vascular resistance (−16.1±18.1%;
P
<0.0001) and an increase in mixed venous saturation during inhaled nitric oxide (9.1±11.6%;
P
<0.0001) were observed. Sixty-two patients underwent pulmonary endarterectomy after a median of 49 days (25th and 75th percentiles: 24 and 123 days). Operated patients were followed up for a median of 70.9 months (25th and 75th percentiles: 14 and 97 months). Change in mPAP during inhaled NO was identified as a predictor of persistent/recurrent pulmonary hypertension after pulmonary endarterectomy. Patients experiencing a reduction in mPAP >10.4% with nitric oxide inhalation had a better postoperative outcome. A significant correlation was found between ΔmPAP and immediate postoperative pulmonary vascular resistance (
r
=0.5,
P
<0.0001).
Conclusions—
A total of 80 (77.7%) of 103 patients demonstrated acute pulmonary vascular reactivity of some degree. A decrease in mPAP >10.4% under inhaled nitric oxide is a predictor of long-term survival and freedom from lung transplantation in adult patients with chronic thromboembolic pulmonary hypertension who are undergoing pulmonary endarterectomy.
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Affiliation(s)
- Nika Skoro-Sajer
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Niklas Hack
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Roela Sadushi-Koliçi
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Diana Bonderman
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Johannes Jakowitsch
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Walter Klepetko
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Mir Ali Reza Hoda
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Meinhard P. Kneussl
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Peter Fedullo
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
| | - Irene M. Lang
- From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif
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Bedard E, Dimopoulos K, Gatzoulis MA. Has there been any progress made on pregnancy outcomes among women with pulmonary arterial hypertension? Eur Heart J 2008; 30:256-65. [DOI: 10.1093/eurheartj/ehn597] [Citation(s) in RCA: 374] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Sildenafil for pulmonary hypertension: Dose-dependent improvement in exercise performance. Pulm Pharmacol Ther 2008; 21:516-21. [DOI: 10.1016/j.pupt.2007.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2007] [Revised: 10/31/2007] [Accepted: 11/29/2007] [Indexed: 11/20/2022]
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Krug S, Hammerschmidt S, Pankau H, Wirtz H, Seyfarth HJ. Acute improved hemodynamics following inhaled iloprost in chronic thromboembolic pulmonary hypertension. ACTA ACUST UNITED AC 2007; 76:154-9. [PMID: 17804899 DOI: 10.1159/000107977] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2006] [Accepted: 06/18/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a potential consequence to pulmonary embolism. The histologic picture is similar to idiopathic pulmonary hypertension (IPAH) suggesting that vascular remodeling also contributes to CTEPH. The treatment of choice is pulmonary endarterectomy. However, this treatment option is not adequate for all patients with CTEPH. Currently, no data exist on standard vasodilative therapy for CTEPH. Intravenous and oral prostanoids, both well-known vasodilators in IPAH, have been used with promising results, whereas the same has not been consistently observed for inhaled iloprost. OBJECTIVE In this study, we examined acute hemodynamic effects of inhaled iloprost in patients with CTEPH. METHODS In a prospective study, right heart catheterization was performed in 20 patients (mean age 56 years, New York Heart Association class II-IV) at the time of diagnosis of CTEPH. Pulmonary vascular resistance (PVR), mean pulmonary arterial pressure (mPAP), cardiac output (CO), mean systemic arterial pressure (MAP) and oxygen partial pressure (PaO(2)) were obtained before and 20 min after inhaling 5 mug iloprost. Subsequently, all patients were evaluated for pulmonary endarterectomy. Six patients were eligible for surgery. RESULTS Significant changes in pulmonary and systemic hemodynamics were observed following the inhalation of iloprost (before to after inhalation): PVR: 1,057 +/- 404.3 to 821.3 +/- 294.3 dyn.s.cm(-5), p < 0.0001; mPAP: 50.55 +/- 8.43 to 45.75 +/- 8.09 mm Hg, p = 0.0002; CO: 3.66 +/- 1.05 to 4.05 +/- 0.91 l/min, p < 0.0106. MAP and PaO(2) decreased significantly (MAP: 94.15 +/- 11.58 to 89.45 +/- 14.29 mm Hg, p = 0.0111; PaO(2): 7.33 +/- 1.17 to 6.64 +/- 1.25 kPa, p = 0.0260). CONCLUSIONS Hemodynamic changes directly following inhalation of iloprost suggest a significant contribution of a reversible component of vasoconstriction to pulmonary arterial hypertension in patients with CTEPH.
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Affiliation(s)
- Sabine Krug
- Department of Respiratory Medicine, University of Leipzig, Leipzig, Germany
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Suntharalingam J, Hughes RJ, Goldsmith K, Doughty N, George P, Toshner M, Sheares KK, Pepke-Zaba J. Acute haemodynamic responses to inhaled nitric oxide and intravenous sildenafil in distal chronic thromboembolic pulmonary hypertension (CTEPH). Vascul Pharmacol 2007; 46:449-55. [PMID: 17368113 DOI: 10.1016/j.vph.2007.01.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Revised: 12/11/2006] [Accepted: 01/26/2007] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although surgery is the treatment of choice for CTEPH, it is not appropriate for patients with surgically inaccessible distal disease. These patients are traditionally managed supportively, but may benefit from newer, more specific vasoactive therapies. This study examines the acute haemodynamic responses to inhaled nitric oxide (iNO) and intravenous sildenafil in this patient population. METHODS Nine patients with de novo distal CTEPH and nine with persistent pulmonary hypertension post-pulmonary endarterectomy (PEA) were enrolled. At right heart catheterisation, following baseline haemodynamic measurements, iNO was administered at 20 ppm for 10 min. Following repeat measurements, iNO was discontinued with a subsequent washout period of 10 min. Sildenafil was then administered intravenously at two doses, to achieve plasma levels equivalent to 25 mg and 50 mg orally, with further measurements obtained at the end of each infusion. RESULTS Significant reductions in mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR) were demonstrated following both iNO (-4.3 mm Hg or -10.3% p=0.001 and -101 dyn/s/cm(5) or -15.6% p<0.001) and sildenafil (-7.4 mm Hg or -16.9% p<0.001 and -188.8 dyn/s/cm(5) or -25.1% p<0.001). Individual mPAP and cardiac output (CO) responses to iNO and sildenafil correlated well, but haemodynamic changes following sildenafil were consistently more marked. There was, however, no difference in effect between the two doses of sildenafil. Although sildenafil caused significant reductions in systemic vascular resistance, the net haemodynamic effect of sildenafil remained pulmonary selective. Subgroup analysis suggested that post-PEA patients were more responsive to both iNO and sildenafil than de novo patients. DISCUSSION Although all but one patient failed to fulfil the formal haemodynamic response criteria typically used in idiopathic pulmonary arterial hypertension (IPAH), subjects displayed significant acute responses to both iNO and sildenafil suggesting that increased vascular tone forms an important component of distal CTEPH. It is possible that these acute haemodynamic responses may translate to improved clinical outcomes, and thus further long term trials of sildenafil in distal CTEPH are warranted.
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Affiliation(s)
- J Suntharalingam
- Pulmonary Vascular Diseases Unit, Papworth Hospital NHS Trust, Papworth Everard, Cambridgeshire, CB3 8RE, UK
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