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Fu Z, Xie W, Gao Q, Zhang S, Zhang Z, Zhang Y, Wang D, Yao T, Wang J, Li X, Sun L, Huang Q, Yang P, Zhai Z. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Disease: Success Rate and Complications among Different Patient Populations. Respiration 2024:1-14. [PMID: 39137746 DOI: 10.1159/000540779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 07/25/2024] [Indexed: 08/15/2024] Open
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) is an effective intervention for patients with chronic thromboembolic pulmonary disease (CTEPD). We aimed to identify the patient group with a low success rate or high complication rate of BPA, which is still unclear. METHODS Both CTEPD patients with or without pulmonary hypertension (CTEPH and NoPH-CTEPD) were included. CTEPH patients were divided into groups with or without pulmonary endarterectomy (PEA-CTEPH and NoPEA-CTEPH). The efficacy and safety of BPA were compared among the groups. RESULTS There were 450, 66, and 41 sessions in the NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD groups, respectively. The success rate (≥1 degree improvement in flow grade) in the PEA-CTEPH group was 94.5%, significantly lower than that in the NoPEA-CTEPH (97.1%) and NoPH-CTEPD (98.4%) groups (p = 0.014). The percentage of complete flow recovery in treated vessels was also lower in PEA-CTEPH group. BPA-related complication rate in NoPEA-CTEPH, PEA-CTEPH, and NoPH-CTEPD patients was 6.1%, 6.0%, and 0.0%, respectively (p = 0.309). One BPA-related death occurred (solely in NoPEA-CTEPH). Mean pulmonary artery pressure ≥41.5 mm Hg was a predictor of BPA-related complications. NoPEA-CTEPH patients had more improvement in 6-min walk distance (6MWD, 87 ± 93 m NoPEA-CTEPH vs. 40 ± 43 m PEA-CTEPH vs. 18 ± 20 m NoPH-CTEPD, p = 0.012). CONCLUSIONS BPA was safe and effective for all CTEPD groups with less improvement for the PEA-CTEPH and NoPH-CTEPD groups. The success rate of BPA was lower in the PEA-CTEPH group and the complication rate was lower in the NoPH-CTEPD group. Pre-BPA treatment to lower pulmonary artery pressure should not be overlooked in CTEPD patients.
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Affiliation(s)
- Zhihui Fu
- China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China,
- Department of Pulmonary and Critical Care Medicine, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, China,
- China State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China,
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
- Department of Integrated TCM and Western Medicine for Pulmonary Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Dingyi Wang
- Department of Clinical Research and Data Management, China-Japan Friendship Hospital, Beijing, China
| | - Ting Yao
- Department of Integrated TCM and Western Medicine for Pulmonary Diseases, China-Japan Friendship Hospital, Beijing, China
| | - Jinzhi Wang
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital, Jiangxi Medical College Nanchang University, Nanchang, China
| | - Xincheng Li
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lu Sun
- China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qiang Huang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Peiran Yang
- State Key Laboratory of Medical Molecular Biology, Department of Physiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhenguo Zhai
- China-Japan Friendship Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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Guarnieri G, Constantin FD, Pedrazzini G, Ruffino MA, Sürder D, Petrino R, Zucconi EC, Gabutti L, Ogna A, Balestra B, Valgimigli M. Integrating Pharmacomechanical Treatments for Pulmonary Embolism Management within a Hub-and-Spoke System in the Swiss Ticino Region. J Clin Med 2024; 13:2457. [PMID: 38730985 PMCID: PMC11084835 DOI: 10.3390/jcm13092457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/12/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
The Swiss Ticino regional pulmonary embolism response team (PERT) features direct access to various pharmacomechanical PE management options within a hub/spoke system, by integrating evidence, guidelines' recommendations and personal experiences. This system involves a collaborative management of patients among the hospitals distributed throughout the region, which refer selected intermediate-high or high PE patients to a second-level hub center, located in Lugano at Cardiocentro Ticino, belonging to the Ente Ospedaliero Cantonale (EOC). The hub provides 24/7 catheterization laboratory activation for catheter-based intervention (CBI), surgical embolectomy and/or a mechanical support system such as extracorporeal membrane oxygenation (ECMO). The hub hosts PE patients after percutaneous or surgical intervention in two intensive care units, one specialized in cardiovascular anesthesiology, to be preferred for patients without relevant comorbidities or with hemodynamic instability and one specialized in post-surgical care, to be preferred for PE patients after trauma or surgery or with relevant comorbidities, such as cancer. From April 2022 to December 2023, a total of 65 patients were referred to the hub for CBI, including ultrasound-assisted catheter-directed thrombolysis (USAT) or large-bore aspiration intervention. No patient received ECMO or underwent surgical embolectomy.
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Affiliation(s)
- Gianluca Guarnieri
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy
| | - Filip David Constantin
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Giovanni Pedrazzini
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Maria Antonella Ruffino
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Daniel Sürder
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
| | - Roberta Petrino
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Enrico Carlo Zucconi
- Ospedale Regionale di Lugano, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (M.A.R.); (R.P.); (E.C.Z.)
| | - Luca Gabutti
- Ospedale Regionale di Bellinzona e Valli, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland;
| | - Adam Ogna
- Ospedale Regionale di Locarno, Ente Ospedaliero Cantonale, 6600 Locarno, Switzerland;
| | - Brenno Balestra
- Ospedale Regionale di Mendrisio, Ente Ospedaliero Cantonale, 6850 Mendrisio, Switzerland;
| | - Marco Valgimigli
- Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland; (G.G.); (F.D.C.); (G.P.); (D.S.)
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Alotaibi M, Yang JZ, Papamatheakis DG, McGuire WC, Fernandes TM, Morris TA. Cardiopulmonary exercise test to detect cardiac dysfunction from pulmonary vascular disease. Respir Res 2024; 25:121. [PMID: 38468264 PMCID: PMC10926602 DOI: 10.1186/s12931-024-02746-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/22/2024] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Cardiac dysfunction from pulmonary vascular disease causes characteristic findings on cardiopulmonary exercise testing (CPET). We tested the accuracy of CPET for detecting inadequate stroke volume (SV) augmentation during exercise, a pivotal manifestation of cardiac limitation in patients with pulmonary vascular disease. METHODS We reviewed patients with suspected pulmonary vascular disease in whom CPET and right heart catheterization (RHC) measurements were taken at rest and at anaerobic threshold (AT). We correlated CPET-determined O2·pulseAT/O2·pulserest with RHC-determined SVAT/SVrest. We evaluated the sensitivity and specificity of O2·pulseAT/O2·pulserest to detect SVAT/SVrest below the lower limit of normal (LLN). For comparison, we performed similar analyses comparing echocardiographically-measured peak tricuspid regurgitant velocity (TRVpeak) with SVAT/SVrest. RESULTS From July 2018 through February 2023, 83 simultaneous RHC and CPET were performed. Thirty-six studies measured O2·pulse and SV at rest and at AT. O2·pulseAT/O2·pulserest correlated highly with SVAT/SVrest (r = 0.72, 95% CI 0.52, 0.85; p < 0.0001), whereas TRVpeak did not (r = -0.09, 95% CI -0.47, 0.33; p = 0.69). The AUROC to detect SVAT/SVrest below the LLN was significantly higher for O2·pulseAT/O2·pulserest (0.92, SE 0.04; p = 0.0002) than for TRVpeak (0.69, SE 0.10; p = 0.12). O2·pulseAT/O2·pulserest of less than 2.6 was 92.6% sensitive (95% CI 76.6%, 98.7%) and 66.7% specific (95% CI 35.2%, 87.9%) for deficient SVAT/SVrest. CONCLUSIONS CPET detected deficient SV augmentation more accurately than echocardiography. CPET-determined O2·pulseAT/O2·pulserest may have a prominent role for noninvasive screening of patients at risk for pulmonary vascular disease, such as patients with persistent dyspnea after pulmonary embolism.
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Affiliation(s)
- Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Jenny Z Yang
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Demosthenes G Papamatheakis
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA
| | - Timothy A Morris
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego Healthcare, 200 West Arbor Drive, San Diego, CA, 92103-8378, USA.
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Huertas Nieto S, Velázquez Martín M, Sarnago Cebada F, Jiménez López-Guarch C, Maneiro Melón N, Flox Camacho Á, Segura de la Cal T, Cruz Utrilla A, Aguilar Colindres R, López Gude MJ, Quezada Loaiza CA, Revilla Ostolaza Y, Alonso Charterina S, Gómez Cuervo C, Arribas Ynsaurriaga F, Escribano Subías P. Value of exercise right heart catheterization in the differential diagnosis of chronic thromboembolic pulmonary disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:158-166. [PMID: 37863183 DOI: 10.1016/j.rec.2023.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/16/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION AND OBJECTIVES Chronic thromboembolic disease refers to the presence of chronic thrombotic pulmonary vascular thrombosis without pulmonary hypertension (PH) at rest but with exercise limitation after pulmonary embolism (PE). Our aim was to evaluate the hemodynamic response to exercise in these patients and its correlation with the values reached in cardiopulmonary exercise testing. METHODS We included symptomatic patients with persistent pulmonary thrombosis after PE. We excluded patients with left heart disease or significant PH (mean pulmonary arterial pressure [mPAP] >25mmHg, pulmonary vascular resistance >3 WU, and pulmonary capillary wedge pressure [PCWP] >15mmHg). Cardiopulmonary exercise testing and exercise right heart catheterization were performed. Exercise-induced precapillary PH was defined as mPAP/CO slope >3 and PCWP/CO slope <2mmHg/l/min. The hemodynamic response and the values obtained in cardiopulmonary exercise testing were compared between patients with and without exercise-induced precapillary PH. RESULTS We studied 36 patients; 4 were excluded due to incomplete hemodynamic data. Out of the 32 patients analyzed; 3 developed a pathological increase in PCWP. Among the remaining 29 patients (mean age, 49.4±13.7 years, 34.5% women), 13 showed exercise-induced PH. Resting mPAP was higher in those who developed exercise-induced PH (23.3±5.4 vs 19.0±3.8mmHg; P=.012), although CO was similar in the 2 groups. Patients with exercise-induced PH exhibited data of ventilatory inefficiency with reduced values of end-tidal CO2 pressure at the anaerobic threshold (32.8±3.0 vs 36.2±3.3mmHg; P=.021) and a higher Ve/VCO2 slope (34.2±4.8 vs 30.7±5.0; P=.049). CONCLUSIONS Exercise limitation and ventilatory inefficiency could be attributable to exercise-induced precapillary PH in a subgroup of patients with persistent pulmonary thrombosis and dyspnea.
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Affiliation(s)
- Sergio Huertas Nieto
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain.
| | - Maite Velázquez Martín
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Fernando Sarnago Cebada
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Carmen Jiménez López-Guarch
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Nicolás Maneiro Melón
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Ángela Flox Camacho
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Teresa Segura de la Cal
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | - Alejandro Cruz Utrilla
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain
| | | | - María Jesús López Gude
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Carlos Andrés Quezada Loaiza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Neumología, Hospital Universitario 12 de Octubre, Madrid, Spain; Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Spain
| | - Yolanda Revilla Ostolaza
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Sergio Alonso Charterina
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Servicio de Radiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Fernando Arribas Ynsaurriaga
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Unidad de Hemodinámica, Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Pilar Escribano Subías
- Unidad Multidisciplinar de Hipertensión Pulmonar, European Reference Network (ERN), Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (i+12), Madrid, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Ghani H, Pepke-Zaba J. Chronic Thromboembolic Pulmonary Hypertension: A Review of the Multifaceted Pathobiology. Biomedicines 2023; 12:46. [PMID: 38255153 PMCID: PMC10813488 DOI: 10.3390/biomedicines12010046] [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: 11/30/2023] [Revised: 12/18/2023] [Accepted: 12/22/2023] [Indexed: 01/24/2024] Open
Abstract
Chronic thromboembolic pulmonary disease results from the incomplete resolution of thrombi, leading to fibrotic obstructions. These vascular obstructions and additional microvasculopathy may lead to chronic thromboembolic pulmonary hypertension (CTEPH) with increased pulmonary arterial pressure and pulmonary vascular resistance, which, if left untreated, can lead to right heart failure and death. The pathobiology of CTEPH has been challenging to unravel due to its rarity, possible interference of results with anticoagulation, difficulty in selecting the most relevant study time point in relation to presentation with acute pulmonary embolism (PE), and lack of animal models. In this article, we review the most relevant multifaceted cross-talking pathogenic mechanisms and advances in understanding the pathobiology in CTEPH, as well as its challenges and future direction. There appears to be a genetic background affecting the relevant pathological pathways. This includes genetic associations with dysfibrinogenemia resulting in fibrinolysis resistance, defective angiogenesis affecting thrombus resolution, and inflammatory mediators driving chronic inflammation in CTEPH. However, these are not necessarily specific to CTEPH and some of the pathways are also described in acute PE or deep vein thrombosis. In addition, there is a complex interplay between angiogenic and inflammatory mediators driving thrombus non-resolution, endothelial dysfunction, and vascular remodeling. Furthermore, there are data to suggest that infection, the microbiome, circulating microparticles, and the plasma metabolome are contributing to the pathobiology of CTEPH.
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Affiliation(s)
- Hakim Ghani
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital, Cambridge CB2 0AY, UK;
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Andraska EA, Bonaroti J, Zhang Y, Rivera-Lebron B, Chaer RA, Avgerinos ED. Predictors of chronic thromboembolic pulmonary hypertension in patients with submassive pulmonary embolism treated with catheter-directed thrombolysis versus anticoagulation alone: A secondary analysis of the SUNSET sPE trial. J Vasc Surg Venous Lymphat Disord 2023; 11:1157-1164. [PMID: 37353154 PMCID: PMC10630068 DOI: 10.1016/j.jvsv.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/19/2023] [Accepted: 06/04/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) is a morbid complication with suboptimal treatment. We aimed to evaluate the biomarker profile and functional outcomes in patients with submassive PE (sPE) treated with catheter-directed thrombolysis (CDT) compared with anticoagulation alone (ACA). We performed a secondary biomarker and survey analysis of the SUNSET sPE (standard vs ultrasound-assisted catheter thrombolysis for submassive pulmonary embolism) randomized trial comparing standard CDT to ultrasound-assisted thrombolysis in patients with sPE. METHODS As a part of the SUNSET sPE study, patients who did not receive an intervention were enrolled in the medical (ACA) arm. The biomarkers associated with CTEPH in the literature (ie, CCL2, CXCL10, PTX3, GDF-15, RAGE, BCA-1, TFPI) were collected and measured using a multiplex assay at diagnosis, discharge, and 3-month follow-up. Patients underwent a 6-minute walk test and answered quality-of-life questionnaires (pulmonary embolism quality of life; University of California, San Diego, shortness of breath questionnaire; 36-item short-form survey) at 3 months after diagnosis. Comparisons were made using the Student t test. Nonparametric tests were used when the distributions were not normal. Significance was set at P ≤ .05. RESULTS A total of 72 patients (age, 56 ± 15 years; 40.3% women) were included in the present analysis. Of these 72 patients, 53 underwent CDT and 19 were included in the ACA arm. The baseline right ventricle/left ventricle ratios were similar between the two groups (CST, 1.8; ACA, 1.7). The survival and complication rates were similar between the two groups. At discharge, CXCL10 (768.9 ± 148.6 pg/mL vs 3032.0 ± 1201.0 pg/mL; P = .018) and PTX3 (3203.5 ± 1298.0 pg/mL vs 12,716.2 ± 6961.5 pg/mL; P = .029) were lower in the CDT group and displayed a quicker return to baseline than in the ACA group. This trend, although not significant, was also seen with the other biomarkers. At 3 months, the 6-minute walking distance and quality-of-life scores were similar between both groups. CONCLUSIONS In patients with sPE, the biomarkers of CTEPH were lower with CDT compared with ACA. At 3 months, both groups demonstrated similar biomarker levels, 6-minute walking distances, and quality-of-life scores.
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Affiliation(s)
- Elizabeth A Andraska
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA.
| | | | - Yingze Zhang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Belinda Rivera-Lebron
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Efthymios D Avgerinos
- Division of Vascular Surgery, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
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Patel S, Thulasidasan N, Thomson B, Mukherjee B, Breen K, Lams B, Karunanithy N. Interventional therapies in acute pulmonary embolus-current trends and future directions. Br J Radiol 2023; 96:20221151. [PMID: 37449941 PMCID: PMC10461285 DOI: 10.1259/bjr.20221151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 07/18/2023] Open
Abstract
Venous thromboembolic disease presenting with acute pulmonary embolus (PE) can be treated in a variety of ways from anticoagulation as an outpatient to surgical embolectomy with many new interventional therapies being developed. Mortality in these patients can be as high as 50% and many of these treatments are also considered to be high risk. Early involvement of a multidisciplinary team and patient risk stratification can aid management decisions in these complex patients who can suddenly deteriorate.In this review, we summarise the evidence behind new and developing interventional therapies in the treatment of high and intermediate-high risk PE including catheter-directed thrombolysis, pharmacomechanical thrombolysis, thromboaspiration and the growing role of extracorporeal membrane oxygenation in the stabilisation and management of this cohort of patients.
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Affiliation(s)
- Sajal Patel
- Department of Interventional Radiology, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Narayanan Thulasidasan
- Department of Interventional Radiology, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Benedict Thomson
- Department of Interventional Radiology, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Bhaskar Mukherjee
- Department of Respiratory Medicine, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Karen Breen
- Thrombosis and Haemophilia Centre, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Boris Lams
- Department of Respiratory Medicine, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom
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8
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İnce S, Özgokçe M, Özkaçmaz S, Dündar İ, Türko E, Ayyıldız VA, Göya C. Comparison of Medical Treatment Efficiency With Shear Wave Elastography Values of Thrombus in Patients With Lower Extremity Deep Vein Thrombosis. Ultrasound Q 2023; 39:158-164. [PMID: 37289425 DOI: 10.1097/ruq.0000000000000643] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
ABSTRACT In lower-extremity deep vein thrombosis (DVT), thrombus age is essential for successful treatment. The aim of our study was to compare the shear wave elastography (SWE) values measured before treatment and achieved lumen patency after treatment in lower-extremity DVT patients with total occlusion. Patients diagnosed with DVT in the acute-subacute stage (<4 week) with total thrombosis in lower extremity were included in this prospective study. Shear wave elastography measurements were performed where the thrombus was most prominent and homogeneous. To evaluate patient response to treatment, lumen patency (partial [>25%] or total recanalization) was examined using color Doppler imaging in the first and third months posttreatment. Shear wave elastography values with and without patency were compared using an independent t test. Among 75 patients in this study, at the first-month color Doppler imaging examination, the SWE values were 1.77 ± 0.49 (1.09-3.03) m/s in patients who achieved lumen patency (n = 42) and 2.21 ± 0.54 (1.24-3.36) m/s in those who did not show lumen patency (n = 33). The difference between the groups' mean elastography value was statistically significant ( P < 0.001). At the third-month examination, the SWE values were 1.76 ± 0.46 (1.09-3.03) m/s in patients with lumen patency (n = 55) and 2.52 ± 0.48 (1.74-3.36) in patients without lumen patency (n = 20). The difference between the 2 groups' mean elastography value was statistically significant ( P < 0.001). We concluded that it is more difficult to achieve lumen patency in veins occluded by thrombus with higher elasto values, and endovascular interventional procedures should be considered during the initial treatment of high SWE value thrombosis.
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Affiliation(s)
- Suat İnce
- Department of Radiology, Van Training and Research Hospital
| | - Mesut Özgokçe
- Department of Radiology, Medical Faculty, Van Yuzuncu Yıl University, Van
| | - Sercan Özkaçmaz
- Department of Radiology, Medical Faculty, Van Yuzuncu Yıl University, Van
| | - İlyas Dündar
- Department of Radiology, Medical Faculty, Van Yuzuncu Yıl University, Van
| | - Ensar Türko
- Department of Radiology, Medical Faculty, Van Yuzuncu Yıl University, Van
| | - Veysel A Ayyıldız
- Department of Radiology, Medical Faculty, Süleyman Demirel University, Isparta, Turkey
| | - Cemil Göya
- Department of Radiology, Medical Faculty, Van Yuzuncu Yıl University, Van
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9
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Yuriditsky E, Horowitz JM, Lau JF. Chronic thromboembolic pulmonary hypertension and the post-pulmonary embolism (PE) syndrome. Vasc Med 2023; 28:348-360. [PMID: 37036116 DOI: 10.1177/1358863x231165105] [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: 04/11/2023]
Abstract
Over a third of patients surviving acute pulmonary embolism (PE) will experience long-term cardiopulmonary limitations. Persistent thrombi, impaired gas exchange, and altered hemodynamics account for aspects of the postpulmonary embolism syndrome that spans mild functional limitations to debilitating chronic thromboembolic pulmonary hypertension (CTEPH), the most worrisome long-term consequence. Though pulmonary endarterectomy is potentially curative for the latter, less is understood surrounding chronic thromboembolic disease (CTED) and post-PE dyspnea. Advances in pulmonary vasodilator therapies and growing expertise in balloon pulmonary angioplasty provide options for a large group of patients ineligible for surgery, or those with persistent postoperative pulmonary hypertension. In this clinical review, we discuss epidemiology and pathophysiology as well as advances in diagnostics and therapeutics surrounding the spectrum of disease that may follow months after acute PE.
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Affiliation(s)
- Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - James M Horowitz
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - Joe F Lau
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
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10
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Robin P, Le Pennec R, Eddy M, Sikora L, Le Roux PY, Carrier M, Couturaud F, Tromeur C, Planquette B, Sanchez O, Pesavento R, Filippi L, Rodger MA, Kovacs MJ, Mallick R, Salaun PY, Le Gal G. Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism: a systematic review and meta-analysis of individual participant data. J Thromb Haemost 2023; 21:1519-1528.e2. [PMID: 36740040 DOI: 10.1016/j.jtha.2023.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/02/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023]
Abstract
We aimed to assess the relationship between residual pulmonary vascular obstruction (RPVO) on planar lung scan after completion of at least 3 months of anticoagulant therapy for acute pulmonary embolism (PE) and the risk of recurrent venous thromboembolism (VTE) or death due to PE one year after treatment discontinuation. The systematic review was registered with the International Prospective Registry of Systematic Reviews (PROSPERO: CRD42017081080). The primary outcome measure was to generate a pooled estimate of the rate of recurrent VTE at one year in patient with RPVO diagnosed on planar lung scan after discontinuation of at least 3 months of anticoagulant treatment for an acute PE. Individual data were obtained for 809 patients. RPVO (ie, obstruction >0%) was found in 407 patients (50.3%) after a median of 6.6 months of anticoagulant therapy for a first acute PE. Recurrent VTE or death due to PE occurred in 114 patients (14.1%), for an annual risk of 6.4% (95% confidence interval, 4.7%-8.6%). Out of the 114 recurrent events, 63 occurred within one year after discontinuation of anticoagulant therapy corresponding to a risk of 8.1% (6.4%-9.8%) at 1 year. The risk of recurrent VTE at one year was 5.8% (4.4-7.2) in participants with RPVO <5%, vs 11.7% (9.5-13.8) in participants with RPVO ≥5%. RPVO is a significant predictor of the risk of recurrent venous thromboembolism. However, the risk of recurrent events remains too high in patients without residual perfusion defect for it to be used as a stand-alone test to decide on anticoagulation discontinuation.
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Affiliation(s)
- Philippe Robin
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Romain Le Pennec
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Maggie Eddy
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Pierre-Yves Le Roux
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Marc Carrier
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada
| | - Francis Couturaud
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Cécile Tromeur
- Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France; Département de Médecine Interne et Pneumologie, Centre Hospitalier Régional Universitaire de Brest, Brest, France
| | - Benjamin Planquette
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | - Olivier Sanchez
- Service de Pneumologie et Soins Intensifs, AP-HP, Hôpital Européen Georges Pompidou, Paris, France; Université de Paris, INSERM, UMRS 1140 Innovations Thérapeutiques en Hémostase, Paris, France
| | | | - Lucia Filippi
- Division of General Medicine, Alto Vicentino Hospital, Santorso, Italy
| | - Marc A Rodger
- Department of Medicine, McGill University, Montreal, QC, Canada
| | | | - Ranjeeta Mallick
- Ottawa Methods Center, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Pierre-Yves Salaun
- Département de Médecine Nucléaire, Centre Hospitalier Universitaire de Brest, Brest, France; Inserm, Univ Brest, CHRU Brest, UMR 1304, GETBO, Brest, France
| | - Grégoire Le Gal
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Thrombosis Research Group, Ottawa, Canada; Centre d'Investigation Clinique, Centre Hospitalier Régional et Universitaire de Brest, Brest, France.
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11
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Han X, Han K, Ma X, Sun R, Wang L, Fang W. The value of ventilation/perfusion scanning and CT pulmonary angiography in predicting chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: a one-year follow-up study. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:2249-2259. [PMID: 37726464 DOI: 10.1007/s10554-022-02629-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/19/2022] [Indexed: 11/28/2022]
Abstract
To investigate the value of ventilation/perfusion (V/Q) scanning and CT pulmonary angiography (PA) in predicting CTEPH development after acute pulmonary embolism (APE). This study was performed in APE patients who had undergone both V/Q and CT PA after 3-month anticoagulation. The residual pulmonary obstructions were assessed based on V/Q and CT PA, and then recorded as pulmonary perfusion detect score (PPDs) and CT pulmonary artery obstruction index (PAOI). The predictive performance of PPDs and CT PAOI for CTEPH were determined and risk factors for predicting CTEPH development were identified. A total of 235 patients with initial diagnosis of APE were included in this study. ROC analysis showed that the AUCs of the PPDs and CT PAOI were 0.957 and 0.895, with corresponding cut-off values of 20.50% and 17.50% for predicting CTEPH development. Neither sensitivity nor specificity differed significantly between PPDs and CT PAOI (Sensitivity: 92.00% vs. 80.00%, P = 0.25; Specificity: 88.10% vs. 89.52%, P = 0.69). The univariable and multivariable logistic regression analysis demonstrated that pulmonary arterial hypertension confirmed by echocardiography at initial APE diagnosis (OR: 6.16, 95%CI: 1.31-29.02, P = 0.02), a PPDs of > 20.50% (OR: 22.95, 95%CI: 2.37-222.19, P = 0.007), and a CT PAOI of > 17.50% (OR: 9.98, 95%CI: 2.06-48.49, P = 0.004) were associated with CTEPH development. Both V/Q and CT PA after 3-month anticoagulation for APE showed great performance in predicting CTEPH development, and V/Q scanning has a tendency to be more sensitive but less specific than CT PA. The residual pulmonary embolism detected by V/Q and CT PA was associated with an increased risk of CTEPH development.
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Affiliation(s)
- Xu Han
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Kai Han
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Xinghong Ma
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Ruoxi Sun
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Lei Wang
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Wei Fang
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Fuwai Hospital, Beijing, China.
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12
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Zagorski J, Neto‐Neves E, Alves NJ, Fisher AJ, Kline JA. Modulation of soluble guanylate cyclase ameliorates pulmonary hypertension in a rat model of chronic thromboembolic pulmonary hypertension by stimulating angiogenesis. Physiol Rep 2022; 10:e15156. [PMID: 35001565 PMCID: PMC8743875 DOI: 10.14814/phy2.15156] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 04/15/2023] Open
Abstract
Acute pulmonary embolism (PE) does not always resolve after treatment and can progress to chronic thromboembolic disease (CTED) or the more severe chronic thromboembolic pulmonary hypertension (CTEPH). The mechanisms surrounding the likelihood of PE resolution or progress to CTED/CTEPH remain largely unknown. We have developed a rat model of CTEPH that closely resembles the human disease in terms of hemodynamics and cardiac manifestations. Embolization of rats with polystyrene microspheres followed by suppression of angiogenesis with the inhibitor of vascular endothelial growth factor receptor 2 (VEGF-R2) SU5416 results in transient, acute pulmonary hypertension that progresses into chronic PE with PH with sustained right ventricular systolic pressures exceeding 70 mmHg (chronic pulmonary embolism [CPE] model). This model is similar to the widely utilized hypoxia/SU5416 model with the exception that the "first hit" is PE. Rats with CPE have impaired right heart function characterized by reduced VO2 Max, reduced cardiac output, and increased Fulton index. None of these metrics are adversely affected by PE alone. Contrast-mediated CT imaging of lungs from rats with PE minus SU5416 show large increases in pulmonary vascular volume, presumably due to an angiogenic response to acute PE/PH. Co-treatment with SU5416 suppresses angiogenesis and produces the CTEPH-like phenotype. We report here that treatment of CPE rats with agonists for soluble guanylate cyclase, a source of cGMP which is in turn a signal for angiogenesis, markedly increases angiogenesis in lungs, and ameliorates the cardiac deficiencies in the CPE model. These results have implications for future development of therapies for human CTEPH.
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Affiliation(s)
- John Zagorski
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Present address:
Department of MedicineIndiana University School of MedicineRiley R2 435, 950 W. Walnut St.IndianapolisIndiana46202USA
| | - Evandro Neto‐Neves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
- Present address:
Department of PharmacologyRiberiao Proto Medical SchoolUniversity of San PauloSau PauloBrazil
| | - Nathan J. Alves
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
| | - Amanda J. Fisher
- Department of AnesthesiaIndiana University School of MedicineIndianapolisIndianaUSA
| | - Jeffrey A. Kline
- Department of Emergency MedicineIndiana University School of MedicineIndianapolisIndianaUSA
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13
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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14
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Özgüven S, Kesim S, Öksüzoğlu K, Yanartaş M, Taş S, Şen F, Öneş T, İnanır S, Turoğlu HT, Mutlu B, Erdil TY, Yıldızeli B. Correlation Between Perfusion Abnormalities Extent in Ventilation/Perfusion SPECT/CT with Hemodynamic Parameters in Patients with Chronic Thromboembolic Pulmonary Hypertension. Mol Imaging Radionucl Ther 2021; 30:28-33. [PMID: 33586404 PMCID: PMC7885277 DOI: 10.4274/mirt.galenos.2020.31932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objectives Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension with persistent pulmonary vascular obstruction and exercise intolerance, which may benefit from pulmonary endarterectomy (PEA). Ventilation/perfusion (V/Q) scan is the preferred screening test of CTEPH, which can be used to assess the anatomical extent of the disease. This study aimed to analyze the correlation between the extent of mismatched Q defects in V/Q single photon emission computed tomography/computed tomography (SPECT/CT) with preoperative clinical and hemodynamic parameters in patients with CTEPH. Methods A total of 102 patients with CTEPH prior to PEA having V/Q SPECT/CT scans were retrospectively reviewed. Age, gender, New York Heart Association classification, intraoperative right-sided heart catheterization (mPAP and PVR), and 6-minute walk test (6MWT) findings were obtained from clinical records of patients. Results Linear regression analysis showed a significant but weak correlation between the preoperative mPAP and PVR with the extent of mismatched Q defects in V/Q SPECT/CT (rs=0.09474 with p=0.0016 and rs=0.045 with p=0.045, respectively). No significant correlation was found between 6MWT and extent of mismatched Q defects in V/Q SPECT/CT (p>0.05). Conclusion A quantitative assessment of Q defects on V/Q SPECT/CT might provide information about hemodynamic parameters in patients with CTEPH.
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Affiliation(s)
- Salih Özgüven
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Selin Kesim
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Kevser Öksüzoğlu
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Mehmed Yanartaş
- University of Health Sciences Turkey, Kartal Koşuyolu Training and Research Hospital, Clinic of Cardiovascular Surgery, İstanbul, Turkey
| | - Serpil Taş
- University of Health Sciences Turkey, Kartal Koşuyolu Training and Research Hospital, Clinic of Cardiovascular Surgery, İstanbul, Turkey
| | - Feyza Şen
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Tunç Öneş
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Sabahat İnanır
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Halil Turgut Turoğlu
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Bülent Mutlu
- Marmara University Pendik Training and Research Hospital, Clinic of Cardiology, İstanbul, Turkey
| | - Tanju Yusuf Erdil
- Marmara University Pendik Training and Research Hospital, Clinic of Nuclear Medicine, İstanbul, Turkey
| | - Bedrettin Yıldızeli
- Marmara University Pendik Training and Research Hospital, Clinic of Thoracic Surgery, İstanbul, Turkey
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15
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Picart G, Robin P, Tromeur C, Orione C, Raj L, Ferrière N, Le Mao R, Le Roux PY, Le Floch PY, Lemarié CA, Nonent M, Leroyer C, Guegan M, Lacut K, Salaün PY, Couturaud F. Predictors of residual pulmonary vascular obstruction after pulmonary embolism: Results from a prospective cohort study. Thromb Res 2020; 194:1-7. [DOI: 10.1016/j.thromres.2020.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 12/01/2022]
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16
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Moradi F, Morris TA, Hoh CK. Perfusion Scintigraphy in Diagnosis and Management of Thromboembolic Pulmonary Hypertension. Radiographics 2020; 39:169-185. [PMID: 30620694 DOI: 10.1148/rg.2019180074] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication of acute pulmonary embolism (PE). Because the treatment of CTEPH is markedly different from that of other types of pulmonary hypertension, lung ventilation-perfusion (V/Q) scintigraphy is recommended for the workup of patients with unexplained pulmonary hypertension. Lung V/Q scintigraphy is superior to CT pulmonary angiography for detecting CTEPH. Perfusion defect findings of CTEPH can be different from those of acute PE. Familiarity with the patterns of perfusion defects seen during the initial workup of CTEPH and the expected posttreatment changes seen at follow-up imaging is essential for accurate interpretation of V/Q scintigraphy findings. ©RSNA, 2019.
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Affiliation(s)
- Farshad Moradi
- From the Department of Radiology, Division of Nuclear Medicine (F.M., C.K.H.); and Division of Pulmonary, Critical Care, and Sleep Medicine (T.A.M.), University of California, San Diego, San Diego, Calif
| | - Timothy A Morris
- From the Department of Radiology, Division of Nuclear Medicine (F.M., C.K.H.); and Division of Pulmonary, Critical Care, and Sleep Medicine (T.A.M.), University of California, San Diego, San Diego, Calif
| | - Carl K Hoh
- From the Department of Radiology, Division of Nuclear Medicine (F.M., C.K.H.); and Division of Pulmonary, Critical Care, and Sleep Medicine (T.A.M.), University of California, San Diego, San Diego, Calif
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17
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Claeys M, Claessen G, La Gerche A, Petit T, Belge C, Meyns B, Bogaert J, Willems R, Claus P, Delcroix M. Impaired Cardiac Reserve and Abnormal Vascular Load Limit Exercise Capacity in Chronic Thromboembolic Disease. JACC Cardiovasc Imaging 2019; 12:1444-1456. [DOI: 10.1016/j.jcmg.2018.07.021] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 07/20/2018] [Accepted: 07/23/2018] [Indexed: 01/14/2023]
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18
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Abstract
Objective: Chronic thromboembolic disease (CTED) is characterized by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment by performing pulmonary endarterectomy (PEA) may improve symptoms. The goal of the study was to review our experience and early outcome of PEA in patients with CTED. Methods: Data were prospectively collected on all patients who underwent PEA between 2011 and 2015. Patients with CTED and a mean pulmonary artery pressure (mPAP) of <25 mm Hg were identified. All patients were in New York Heart Association (NYHA) functional class II or III. Measured outcomes were in-hospital complications, improvement in cardiac function and exercise capacity, and survival after PEA. Patients were reassessed at 6 months following surgery. Results: A total of 23 patients underwent surgery. There was no in-hospital mortality, but complications occurred in six patients (26%). At 6 months following surgery, 93% of the patients remained alive. Following PEA, the mPAP fell significantly from 21.0±2.7 mm Hg to 18.2±5.5 mm Hg (p<.001). Pulmonary vascular resistance also significantly decreased from 2.2±0.7 wood to 1.5±0.5 wood (p<.001). The 6-min walking distance significantly increased from 322.6±80.4 m to 379.9±68.2 m (p<.001). There was a significant symptomatic improvement in all survivors in NYHA functional classes I or II at 6 months following surgery (p=.001). Conclusion: PEA in selected patients with CTED resulted in significant improvement in symptoms. The selection of patients for undergoing PEA in the absence of pulmonary hypertension must be made based on patients’ expectations and their acceptance of the perioperative risk.
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Xi XY, Gao W, Gong JN, Guo XJ, Wu JY, Yang YH, Yang MF. Value of 18F-FDG PET/CT in differentiating malignancy of pulmonary artery from pulmonary thromboembolism: a cohort study and literature review. Int J Cardiovasc Imaging 2019; 35:1395-1403. [PMID: 30747369 DOI: 10.1007/s10554-019-01553-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 02/02/2019] [Indexed: 02/08/2023]
Abstract
To determine the value of 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) in differentiating malignancy of pulmonary artery (PA) from pulmonary thromboembolism (PTE) based on a larger number of cases by pooling our cases and those from the literature. Consecutive patients with a PA lesion who had undergone 18F-FDG PET/CT in our hospital were retrospectively reviewed. Moreover, PubMed, Embase, and Medline were searched for literature reporting individual maximum standardised uptake value (SUVmax) of the malignant PA lesion and/or PTE. 18F-FDG activity was compared between PA malignancy and PTE by pooling the data from literature and our patients. Receiver operating characteristic curve analysis was performed to determine the ability of SUVmax to differentiate PA malignancy from PTE. From our database, we identified 11 patients with pulmonary artery sarcoma (PAS), and nine cases of PTE. Fifty patients with a malignant PA lesion (40 cases of PAS and 10 cases of tumor embolism) and 22 subjects with PTE were extracted from the literature. In our cases, the SUVmax of PAS (11.1 ± 4.9, range: 5.5-19.9) was significantly higher than that of PTE (1.9 ± 0.6, range: 1.1-3.2; P < 0.001). There was no significant difference in the SUVmax between the literature data and our cases in malignant lesions or in PTE. Based on the pooled analysis of the literature data and our cases (61 cases of malignant lesions and 31 cases of PTE), the area under the curve for SUVmax to differentiate PA malignancy from PTE was 0.996 (95% CI: 0.989-1.000). At a cutoff value of 3.3, the sensitivity, specificity, and accuracy were 98.4%, 96.8%, and 97.8%, respectively. The 18F-FDG uptake value is an accurate index for determining PA malignancy.
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Affiliation(s)
- Xiao-Ying Xi
- Department of Nuclear Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8th Gongtinanlu Rd, Chaoyang District, Beijing, 100020, China
| | - Wei Gao
- Department of Ultrasound, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Juan-Ni Gong
- Department of Respiratory and Critical Care, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiao-Juan Guo
- Department of Radiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Jiao-Yan Wu
- Department of Nuclear Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8th Gongtinanlu Rd, Chaoyang District, Beijing, 100020, China
| | - Yuan-Hua Yang
- Department of Respiratory and Critical Care, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Min-Fu Yang
- Department of Nuclear Medicine, Beijing Chaoyang Hospital, Capital Medical University, 8th Gongtinanlu Rd, Chaoyang District, Beijing, 100020, China.
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20
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Planquette B, Sanchez O, Marsh JJ, Chiles PG, Emmerich J, Le Gal G, Meyer G, Wolfson T, Gamst AC, Moore RE, Gugiu GB, Morris TA. Fibrinogen and the prediction of residual obstruction manifested after pulmonary embolism treatment. Eur Respir J 2018; 52:13993003.01467-2018. [PMID: 30337447 DOI: 10.1183/13993003.01467-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Accepted: 09/24/2018] [Indexed: 11/05/2022]
Abstract
Residual pulmonary vascular obstruction (RPVO) and chronic thromboembolic pulmonary hypertension (CTEPH) are both long-term complications of acute pulmonary embolism, but it is unknown whether RPVO can be predicted by variants of fibrinogen associated with CTEPH.We used the Akaike information criterion to select the best predictive models for RPVO in two prospectively followed cohorts of acute pulmonary embolism patients, using as candidate variables the extent of the initial obstruction, clinical characteristics and fibrinogen-related data. We measured the selected models' goodness of fit by analysis of deviance and compared models using the Chi-squared test.RPVO occurred in 29 (28.4%) out of 102 subjects in the first cohort and 46 (25.3%) out of 182 subjects in the second. The best-fit predictive model derived in the first cohort (p=0.0002) and validated in the second cohort (p=0.0005) implicated fibrinogen Bβ-chain monosialylation in the development of RPVO. When the derivation procedure excluded clinical characteristics, fibrinogen Bβ-chain monosialylation remained a predictor of RPVO in the best-fit predictive model (p=0.00003). Excluding fibrinogen characteristics worsened the predictive model (p=0.03).Fibrinogen Bβ-chain monosialylation, a common structural attribute of fibrin, helped predict RPVO after acute pulmonary embolism. Fibrin structure may contribute to the risk of developing RPVO.
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Affiliation(s)
- Benjamin Planquette
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM UMR-S 1140, Paris, France
| | - Olivier Sanchez
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM UMR-S 1140, Paris, France
| | - James J Marsh
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Peter G Chiles
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
| | - Joseph Emmerich
- Université Paris Descartes, Sorbonne Paris Cité, France.,Médecine Vasculaire - Cardiologie, Centre de Diagnostic et de Thérapeutique, Hôpital Hôtel Dieu, AP-HP, Paris, France
| | - Grégoire Le Gal
- Dept of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Guy Meyer
- Université Paris Descartes, Sorbonne Paris Cité, France.,Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM CIC-1418, Paris, France.,INSERM UMR-S 970, Paris, France
| | - Tanya Wolfson
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California San Diego, San Diego, CA, USA
| | - Anthony C Gamst
- Computational and Applied Statistics Laboratory (CASL), San Diego Supercomputer Center, University of California San Diego, San Diego, CA, USA
| | - Roger E Moore
- Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Gabriel B Gugiu
- Beckman Research Institute of the City of Hope, Duarte, CA, USA
| | - Timothy A Morris
- Dept of Medicine, Division of Pulmonary and Critical Care Medicine, University of California, San Diego, CA, USA
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21
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Chronic Thromboembolic Pulmonary Hypertension. The Journey from a Curiosity to a Cure. Ann Am Thorac Soc 2018; 13 Suppl 3:S197-200. [PMID: 27571000 DOI: 10.1513/annalsats.201509-618as] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive and life-threatening condition that is believed to be related to inadequate dissolution of acute pulmonary thromboemboli, followed by fibrotic organization. Without appropriate treatment, progressive pulmonary hypertension, right ventricular failure, and death may occur. While the disorder was initially described nearly a century ago in autopsy studies, antemortem diagnosis became feasible with the advent of cardiac catheterization and angiography techniques in the 1940s, while surgical thromboendarterectomy was not attempted until the 1960s. However, this procedure initially had high mortality rates until refinements in management and surgical techniques resulted in much improved outcomes starting in the 1980s. Many questions remain about the pathophysiology and epidemiology of this condition, with unclear contributions of genetics and environmental exposures. The optimal approach to diagnosis also continues to evolve, with improvements in preoperative imaging and hemodynamic assessment. Treatment of chronic thromboembolic pulmonary hypertension has not remained static, as surgical techniques continue to improve and newer pharmacological treatments and percutaneous catheter-based interventions may play therapeutic roles in selected patients. This is the introductory article of a series that provides a state-of-the-art review of chronic thromboembolic pulmonary hypertension.
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Czaplicki C, Albadawi H, Partovi S, Gandhi RT, Quencer K, Deipolyi AR, Oklu R. Can thrombus age guide thrombolytic therapy? Cardiovasc Diagn Ther 2017; 7:S186-S196. [PMID: 29399522 DOI: 10.21037/cdt.2017.11.05] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Venous thrombosis (VT) is a common yet complex clinical condition that has shown minimal alteration in clinical management for decades. It is well known that thrombus evolves structurally over time, with complex changes resulting from the interplay between coagulation factors, cytokines, leukocytes and a myriad of other factors. Our current treatment options are most effective in the acute thrombus, which is composed predominantly of a loose mesh of fibrin and red blood cells (RBCs), making current anticoagulation therapies and thrombolytics quite effective in treatment. Later stages of thrombus are more cellular containing leukocytes, and develop a fibrotic collagenous framework that is more resistant to our current treatments. Understanding the biology of an evolving thrombus will allow us to tailor our treatment and optimize outcomes, as well as focus on novel therapies for the treatment of chronic thrombus. Given the morbidity and mortality of both post thrombotic syndrome (PTS) in patients with deep VT, as well as chronic thromboembolic pulmonary hypertension (CTEPH) in patients with pulmonary embolism (PE), new and innovative therapies must continue to be explored to help prevent these potentially devastating conditions.
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Affiliation(s)
| | - Hassan Albadawi
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
| | - Sasan Partovi
- University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Ripal T Gandhi
- Miami Cardiac and Vascular Institute, University of South Florida College of Medicine, Kendall, FL, USA
| | - Keith Quencer
- Department of Radiology, University of California San Diego Medical Center, San Diego, CA, USA
| | - Amy R Deipolyi
- Department of Interventional Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Rahmi Oklu
- Division of Vascular & Interventional Radiology, Mayo Clinic, Phoenix, AZ, USA
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23
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Lankeit M, Krieg V, Hobohm L, Kölmel S, Liebetrau C, Konstantinides S, Hamm CW, Mayer E, Wiedenroth CB, Guth S. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2017; 37:S1053-2498(17)31877-6. [PMID: 28750932 DOI: 10.1016/j.healun.2017.06.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/23/2017] [Accepted: 06/26/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Management and outcome of patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) who underwent pulmonary endarterectomy (PEA) at a large German referral center were investigated. METHODS In Germany, 394 PEAs were performed in 2014 and 2015 with an in-hospital mortality rate of 5.8%. Of these, 253 patients (64.2%) were treated at the Kerckhoff Clinic, Bad Nauheim, and 237 (93.7%; median age, 62 years [interquartile range [IQR], 52-72 years]; 46.0% female) were included in the present analysis. RESULTS On referral, 52 patients (22.0%) were treated with pulmonary arterial hypertension-specific drugs and 95 (40.4%) were treated with non-vitamin K-dependent oral anticoagulants, and 14 (5.9%) had mean pulmonary artery pressure <25 mm Hg and were classified as having chronic thromboembolic pulmonary vascular disease. PEA was feasible in 236 (99.6%) patients with median duration of surgery of 397 minutes (IQR, 363-431 minutes). Periprocedural (0%) and in-hospital (2.5%) mortality rates were very low. Forty-two patients (17.7%) had intraoperative complications, and 60 (25.3%) had post-operative complications. The duration of surgery was the only predictor of in-hospital mortality (≥500 minutes; odds ratio [OR], 32.0; 95% confidence interval [CI], 5.5-187.6) and the only independent predictor of intraoperative (≥440 minutes; OR, 10.8; 95% CI, 4.4-26.5) and post-operative (≥390 minutes; OR, 2.4; 95%CI, 1.1-5.7) complications. Only intraoperative complications independently predicted a longer duration of surgery (≥397 minutes; OR, 5.0; 95% CI, 2.2-11.2). CONCLUSIONS In an experienced center with multidisciplinary diagnostic and therapeutic approaches, PEA is safe. Prognosis was mainly determined by occurrence of intraoperative complications and duration of surgery rather than patients' pre-operative status.
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Affiliation(s)
- Mareike Lankeit
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany; Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité-University Medicine Berlin, Germany; German Centre for Cardiovascular Research, partner site Berlin, Berlin, Germany.
| | - Valentin Krieg
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Lukas Hobohm
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany; Centre for Cardiology, Cardiology I, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Sebastian Kölmel
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Christoph Liebetrau
- Department of Cardiology, Kerckhoff Clinic, Bad Nauheim, Germany; German Centre for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany
| | - Stavros Konstantinides
- Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Christian W Hamm
- Department of Cardiology, Kerckhoff Clinic, Bad Nauheim, Germany; German Centre for Cardiovascular Research, partner site RheinMain, Frankfurt am Main, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
| | | | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Clinic, Bad Nauheim, Germany
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