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Chen Y, Liang J, Li Q, Zhou J, Xu J, Xiong D, Jiang H, Ye S, Chen J. Clinical outcome of lung transplantation for chronic thromboembolic pulmonary hypertension. BMC Pulm Med 2024; 24:410. [PMID: 39187801 PMCID: PMC11346220 DOI: 10.1186/s12890-024-03213-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 08/09/2024] [Indexed: 08/28/2024] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension with a low incidence. Despite pulmonary endarterectomy(PEA) being the preferred treatment for CTEPH, for patients who failed medical therapy and who are not suitable candidates for PEA, lung transplantation (LT) is still the only effective treatment for end-stage CTEPH; however, there are currently very few reports on the efficacy of LT for CTEPH. METHODS We retrospectively analyzed the clinical data of seven patients diagnosed with CTEPH between July 2019 and July 2021. The follow-up deadline was March, 2022. RESULTS The mean age at admission was 54 ± 12 years. The average value of mean pulmonary artery pressure (mPAP) was 40 ± 5 mmHg. The mean preoperative oxygenation index(PaO2/FiO2) was 203 ± 56 mm Hg. After evaluation, one patient underwent left LT and the rest underwent bilateral LT. Three patients received intraoperative veno-venous extracorporeal membrane oxygenation (ECMO) support, and four patients received intraoperative veno-arterial ECMO support. The average postoperative mPAP was 19 ± 4 mmHg. The mean postoperative oxygenation index(PaO2/FiO2) was 388 ± 83 mmHg. There was a significant difference between the preoperative and postoperative mPAP and oxygenation index(PaO2/FiO2). All patients recovered well and were discharged 37 ± 19 days postoperatively. The mean follow-up duration was 19 ± 8 months. There was no recurrence of CTEPH. CONCLUSIONS LT is an effective treatment for end-stage CTEPH, which can improve cardiopulmonary function and quality of life and prolong survival. Patients who are unable to tolerate PEA should be considered for LT as early as possible when internal medicine failed.
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Affiliation(s)
- Yuan Chen
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Jialong Liang
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Qian Li
- The Taihu Rehabilitation Hospital of Jiangsu Province (The Taihu Sanatorium of Jiangsu Province), Wuxi, Jiangsu, China
| | - Jintao Zhou
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Jian Xu
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Dian Xiong
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Huachi Jiang
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China
| | - Shugao Ye
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China.
| | - Jingyu Chen
- Wuxi Lung Transplant Center, Department of Thoracic Surgery, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, 299 Qingyang Road, Wuxi, 214023, Jiangsu, China.
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Simeone B, Maggio E, Schirone L, Rocco E, Sarto G, Spadafora L, Bernardi M, D’Ambrosio L, Forte M, Vecchio D, Valenti V, Sciarretta S, Vizza CD. Chronic Thromboembolic Pulmonary Hypertension: the therapeutic assessment. Front Cardiovasc Med 2024; 11:1439411. [PMID: 39171327 PMCID: PMC11337617 DOI: 10.3389/fcvm.2024.1439411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 07/16/2024] [Indexed: 08/23/2024] Open
Abstract
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) is a severe and complex condition that evolves from unresolved pulmonary embolism, leading to fibrotic obstruction of pulmonary arteries, pulmonary hypertension, and potential right heart failure. The cornerstone of CTEPH management lies in a multifaceted therapeutic approach tailored to individual patient profiles, reflecting the disease's heterogeneity. This review delves into the current therapeutic strategies for CTEPH, including surgical pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), and targeted pharmacological treatments such as PDE5 inhibitors, endothelin receptor antagonists, sGC stimulators, and prostanoids. Lifelong anticoagulation is also highlighted as a preventive strategy against recurrent thromboembolism. Special emphasis is placed on the interdisciplinary nature of CTEPH care, necessitating collaboration among PEA surgeons, BPA interventionists, PH specialists, and thoracic radiologists to ensure comprehensive treatment planning and execution. The review underscores the importance of selecting an appropriate treatment modality based on the patient's specific disease characteristics and the evolving landscape of CTEPH treatment, aiming to improve patient outcomes through integrated care strategies.
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Affiliation(s)
- Beatrice Simeone
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Enrico Maggio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Erica Rocco
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Gianmarco Sarto
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luigi Spadafora
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Marco Bernardi
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luca D’Ambrosio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Maurizio Forte
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
| | - Daniele Vecchio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valentina Valenti
- Department of Cardiology, Santa Maria Goretti Hospital, Latina, Italy
| | - Sebastiano Sciarretta
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
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Inácio Cazeiro D, Azaredo Raposo M, Guimarães T, Lousada N, Jenkins D, R Inácio J, Moreira S, Mineiro A, Freitas C, Martins S, Ferreira R, Luís R, Cardim N, Pinto FJ, Plácido R. Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies. Rev Port Cardiol 2024:S0870-2551(24)00187-2. [PMID: 38945473 DOI: 10.1016/j.repc.2024.04.006] [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: 11/22/2023] [Revised: 04/09/2024] [Accepted: 04/17/2024] [Indexed: 07/02/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.
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Affiliation(s)
- Daniel Inácio Cazeiro
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Miguel Azaredo Raposo
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Tatiana Guimarães
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Nuno Lousada
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - David Jenkins
- Cardiothoracic Surgery Department, Royal Papworth Hospital, Cambridge, UK
| | - João R Inácio
- Radiology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Susana Moreira
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana Mineiro
- Pulmonology Department, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Céline Freitas
- Association for Research and Development of Faculty of Medicine (AIDFM), Cardiovascular Research Support Unit (GAIC), Lisbon, Portugal
| | - Susana Martins
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Ricardo Ferreira
- Cardiothoracic Surgery Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rita Luís
- Pathology Department, Centro Hospitalar Universitário Lisboa Central, Lisbon, Portugal
| | - Nuno Cardim
- Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal
| | - Fausto J Pinto
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal
| | - Rui Plácido
- Cardiology Department, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL, Faculty of Medicine, Lisbon, Portugal; Cardiology Department, CUF Descobertas Hospital, Lisbon, Portugal.
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4
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Beijk MAM, Winkelman JA, Eckmann HM, Samson DA, Widyanti AP, Vleugels J, Bombeld DCM, Meijer CGCM, Bogaard HJ, Noordegraaf AV, de Bruin-Bon HACM, Bouma BJ. Notch ratio in pulmonary flow predicts long-term survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Heart Vessels 2024:10.1007/s00380-024-02422-5. [PMID: 38837085 DOI: 10.1007/s00380-024-02422-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 05/23/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Assessment of the pattern of the RV outflow tract Doppler provides insights into the hemodynamics of chronic thromboembolic pulmonary hypertension (CTEPH). We studied whether pre-operative assessment of timing of the pulmonary flow systolic notch by Doppler echocardiography is associated with long-term survival after pulmonary endarterectomy (PEA) for CTEPH. METHODS Fifty-nine out of 61 consecutive CETPH patients (mean age 53 ± 14 years, 34% male) whom underwent PEA between June 2002 and June 2005 were studied. Clinical, echocardiographic and hemodynamic variables were assessed pre-operatively and repeat echocardiography was performed 3 months after PEA. Notch ratio (NR) was assessed with pulsed Doppler and calculated as the time from onset of pulmonary flow until notch divided by the time from notch until end of pulmonary flow. Long-term follow-up was obtained between May 2021 and February 2022. RESULTS Pre-operative mean pulmonary artery pressure (mPAP) was 45 ± 15 mmHg and pulmonary vascular resistance (PVR) was 646 ± 454 dynes.s.cm-5. Echocardiography before PEA showed that 7 patients had no notch, 33 had a NR < 1.0 and 19 had a NR > 1.0. Three months after PEA, echocardiography revealed a significant decrease in sPAP in long-term survivors with a NR < 1.0 and a NR > 1.0, while a significant increase in TAPSE/sPAP was only observed in the NR < 1.0 group. Mean long-term clinical follow-up was 14 ± 6 years. NR was significantly different between survivors and non-survivors (0.73 ± 0.25 vs. 1.1 ± 0.44, p < 0.001) but no significant differences were observed in mPAP or PVR. Long-term survival at 14 years was significantly better in patients with a NR < 1.0 compared to patients with a NR > 1.0 (83% vs. 37%, p = < 0.001). CONCLUSION Pre-operative assessment of NR is a predictor of long-term survival in CTEPH patients undergoing PEA, with low mortality risk in patients with NR < 1.0. Long-term survivors with a NR < 1.0 and NR > 1.0 had a significant decrease in sPAP after PEA. However, the TAPSE/sPAP only significantly increased in the NR < 1.0 group. In the NR < 1.0 group, the 6-min walk test increased significantly between pre-operative and at 1-year post-operative follow-up. NR is a simple echocardiographic parameter that can be used in clinical decision-making for PEA.
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Affiliation(s)
- M A M Beijk
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - J A Winkelman
- Department of Cardiothoracic Surgery, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H M Eckmann
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D A Samson
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - A P Widyanti
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J Vleugels
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D C M Bombeld
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - C G C M Meijer
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - H J Bogaard
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - A Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - H A C M de Bruin-Bon
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - B J Bouma
- Department of Cardiology, Heart Center, Amsterdam UMC, Amsterdam Cardiovascular Sciences, Room B2-250, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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5
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Moore J, Altschul E, Remy-Jardin M, Raoof S. Chronic Thromboembolic Pulmonary Hypertension: Clinical and Imaging Evaluation. Clin Chest Med 2024; 45:405-418. [PMID: 38816096 DOI: 10.1016/j.ccm.2024.02.012] [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: 06/01/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and is an important cause of pulmonary hypertension. As a clinical entity, it is frequently underdiagnosed with prolonged diagnostic delays. This study reviews the clinical and radiographic findings associated with CTEPH to improve awareness and recognition. Strengths and limitations of multiple imaging modalities are reviewed. Accompanying images are provided to supplement the text and provide examples of important findings for the reader.
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Affiliation(s)
- Jonathan Moore
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Erica Altschul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Univ.Lille, CHU Lille, LILLE F-59000, France; Univ.Lille, CHU Lille, ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, LILLE F-59000, France
| | - Suhail Raoof
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA.
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Páez-Carpio A, Vollmer I, Zarco FX, Matute-González M, Domenech-Ximenos B, Serrano E, Barberà JA, Blanco I, Gómez FM. Imaging of chronic thromboembolic pulmonary hypertension before, during and after balloon pulmonary angioplasty. Diagn Interv Imaging 2024; 105:215-226. [PMID: 38413273 DOI: 10.1016/j.diii.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/07/2024] [Accepted: 02/09/2024] [Indexed: 02/29/2024]
Abstract
Balloon pulmonary angioplasty (BPA) has recently been elevated as a class I recommendation for the treatment of inoperable or residual chronic thromboembolic pulmonary hypertension (CTEPH). Proper patient selection, procedural safety, and post-procedural evaluation are crucial in the management of these patients, with imaging work-up playing a pivotal role. Understanding the diagnostic and therapeutic imaging algorithms of CTEPH, the imaging features of patients amenable to BPA, all imaging findings observed during and immediately after the procedure and the changes observed during the follow-up is crucial for all interventional radiologists involved in the care of patients with CTEPH. This article illustrates the imaging work-up of patients with CTEPH amenable to BPA, the imaging findings observed before, during and after BPA, and provides a detailed description of all imaging modalities available for CTEPH evaluation.
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Affiliation(s)
- Alfredo Páez-Carpio
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Department of Medical Imaging, University of Toronto, Toronto M5T 1W7, ON, Canada; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain.
| | - Ivan Vollmer
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | - Federico X Zarco
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain
| | | | | | - Elena Serrano
- Department of Radiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat 08907, Spain
| | - Joan A Barberà
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Isabel Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, ICR, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid 28029, Spain
| | - Fernando M Gómez
- Interventional Radiology Unit, Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain; Interventional Radiology Unit, Department of Radiology, The Netherlands Cancer Institute, Amsterdam 1066 CX, the Netherlands
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7
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Krigere A, Kalejs VR, Kaulins R, Rudzitis A, Bondare L, Sablinskis M, Lejnieks A, Kigitovica D, Kurzyna M, Skride A. The Initial Experience of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension in Latvia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:568. [PMID: 38674214 PMCID: PMC11052274 DOI: 10.3390/medicina60040568] [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: 01/14/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Background: Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent pulmonary hypertension after pulmonary endarterectomy (PEA) include targeted medical therapy and balloon pulmonary angioplasty (BPA). BPA is an emerging treatment modality that has been reported to improve functional capacity, pulmonary hemodynamics, and right ventricular function. Reports from expert centers are promising, but more data are needed to make the results more generalizable. Materials and Methods: We conducted a prospective analysis of nine consecutive CTEPH patients who underwent balloon pulmonary angioplasty (BPA) sessions at Pauls Stradins Clinical University Hospital in Riga, Latvia between 1 April 2022 and 1 July 2023. We assessed World Health Organization (WHO) functional class, 6 min walk distance (6MWD), blood oxygen saturation (SpO2), brain natriuretic peptide (BNP) level at baseline and 3 months after the first BPA session. For two patients on whom repeated BPA sessions were performed, we additionally assessed cardiac output (CO), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (mPAP). Results: A total of 12 BPA procedures for nine patients were performed; repeated BPA sessions were performed for two patients. Our results show a reduction in BNP levels and improvement in WHO functional class, 6MWD, and SpO2 after the first BPA session. Improvement in 6MWD was statistically significant. Additionally, an improvement in pulmonary hemodynamic parameters was observed. Conclusions: Our data show that BPA is an effective interventional treatment modality, improving both the pulmonary hemodynamics and functional status. Moreover, BPA is safe and excellently tolerated.
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Affiliation(s)
- Anna Krigere
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Verners Roberts Kalejs
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Ricards Kaulins
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Ainars Rudzitis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Liga Bondare
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Matiss Sablinskis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
- Department of Internal Diseases, Riga East Clinical University Hospital, 1038 Riga, Latvia
| | - Dana Kigitovica
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Andris Skride
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
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8
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Nguyen R, Murra A, Capdeville M. Chronic Thromboembolic Pulmonary Hypertension Due to a Rare Anterior Mediastinal Venous Malformation. J Cardiothorac Vasc Anesth 2024; 38:552-557. [PMID: 36528502 DOI: 10.1053/j.jvca.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel Nguyen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Ali Murra
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Michelle Capdeville
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.
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9
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Bochenek ML, Saar K, Nazari-Jahantigh M, Gogiraju R, Wiedenroth CB, Münzel T, Mayer E, Fink L, Schober A, Hübner N, Guth S, Konstantinides S, Schäfer K. Endothelial Overexpression of TGF-β-Induced Protein Impairs Venous Thrombus Resolution: Possible Role in CTEPH. JACC Basic Transl Sci 2024; 9:100-116. [PMID: 38362348 PMCID: PMC10864968 DOI: 10.1016/j.jacbts.2023.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 02/17/2024]
Abstract
Endothelial cells play a critical role during venous thrombus remodeling, and unresolved, fibrotic thrombi with irregular vessels obstruct the pulmonary artery in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study sought to identify endothelial mediators of impaired venous thrombus resolution and to determine their role in the pathogenesis of the vascular obstructions in patients with CTEPH. Endothelial cells outgrown from pulmonary endarterectomy specimens (PEA) were processed for mRNA profiling, and nCounter gene expression and immunohistochemistry analysis of PEA tissue microarrays and immunoassays of plasma were used to validate the expression in CTEPH. Lentiviral overexpression in human pulmonary artery endothelial cells (HPAECs) and exogenous administration of the recombinant protein into C57BL/6J mice after inferior Vena cava ligation were employed to assess their role for venous thrombus resolution. RT2 PCR profiler analysis demonstrated the significant overexpression of factors downstream of transforming growth factor beta (TGFβ), that is TGFβ-Induced Protein (TGFBI or BIGH3) and transgelin (TAGLN), or involved in TGFβ signaling, that is follistatin-like 3 (FSTL3) and stanniocalcin-2 (STC2). Gene expression and immunohistochemistry analysis of tissue microarrays localized potential disease candidates to vessel-rich regions. Lentiviral overexpression of TGFBI in HPAECs increased fibrotic remodeling of human blood clots in vitro, and exogenous administration of recombinant TGFBI in mice delayed venous thrombus resolution. Significantly elevated plasma TGFBI levels were observed in patients with CTEPH and decreased after PEA. Our findings suggest that overexpression of TGFBI in endothelial promotes venous thrombus non-resolution and fibrosis and is causally involved in the pathophysiology of CTEPH.
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Affiliation(s)
- Magdalena L. Bochenek
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Germany
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, RheinMain, Germany
| | - Kathrin Saar
- Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Maliheh Nazari-Jahantigh
- Institute for Prophylaxis and Epidemiology of Cardiovascular Diseases, Clinic of the University of Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Munich, Germany
| | - Rajinikanth Gogiraju
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, RheinMain, Germany
| | | | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, RheinMain, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Ludger Fink
- Institute for Pathology, Cytology and Molecular Pathology, MVZ, Wetzlar, Germany
| | - Andreas Schober
- Institute for Prophylaxis and Epidemiology of Cardiovascular Diseases, Clinic of the University of Munich, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Munich, Germany
| | - Norbert Hübner
- Max-Delbrück-Center for Molecular Medicine, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Berlin, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | | | - Katrin Schäfer
- Department of Cardiology, Cardiology I, University Medical Center Mainz, Germany
- Deutsches Zentrum für Herz-Kreislauf-Forschung, RheinMain, Germany
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10
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Verbelen T, Godinas L, Dorfmüller P, Gopalan D, Condliffe R, Delcroix M. Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2023; 32:230149. [PMID: 38123236 PMCID: PMC10731457 DOI: 10.1183/16000617.0149-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
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11
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Cerny V, Pagac J, Novak M, Jansa P. Semi-automatic quantification of mosaic perfusion of lung parenchyma and its correlation with haemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension. Clin Radiol 2023; 78:e918-e924. [PMID: 37661531 DOI: 10.1016/j.crad.2023.08.008] [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: 02/07/2023] [Revised: 06/18/2023] [Accepted: 08/10/2023] [Indexed: 09/05/2023]
Abstract
AIM To investigate the feasibility of semiautomatic quantification of mosaic perfusion and the associations between mosaic perfusion on computed tomography (CT; the ratio of hypoperfused parenchyma to the whole lung volume) and haemodynamic parameters through linear regression analysis. MATERIALS AND METHODS Fifty-eight consecutive patients (mean age 66 years, 28 females) diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH) in General University Hospital, Prague, in 2021 were evaluated retrospectively and underwent both right heart catheterisation and CT pulmonary angiography. The parameters derived from the CT examinations were correlated with the recorded haemodynamic parameters. RESULTS A method was developed for semiautomatic detection of hypoperfused tissue from CT using widely available software and a statistically significant correlation was found between the proportion of hypoperfused parenchyma and the mean pulmonary artery pressure (mPAP; R2 0.22; p<0.01) and pulmonary vascular resistance (PVR; R2 0.09; p<0.05). CONCLUSIONS The developed method facilitates the quantification of mosaic perfusion, which is associated with important haemodynamic parameters (mPAP and PVR) in patients with CTEPH.
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Affiliation(s)
- V Cerny
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic.
| | - J Pagac
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic
| | - M Novak
- Department of Radiology, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic
| | - P Jansa
- 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, U Nemocnice 2, 128 08 Prague, Czech Republic
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12
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Ito R, Yamashita J, Ikeda S, Nakajima Y, Kasahara T, Sasaki Y, Suzuki S, Takahashi L, Komatsu I, Murata N, Shimahara Y, Ogino H, Chikamori T. Predictors of procedural complications in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. J Cardiol 2023; 82:497-503. [PMID: 37380068 DOI: 10.1016/j.jjcc.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/02/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) is an effective treatment for inoperable chronic thromboembolic pulmonary hypertension, with good results reported for residual pulmonary hypertension (PH) after pulmonary endarterectomy (PEA). However, BPA is associated with complications, such as pulmonary artery perforation and vascular injury, which can lead to critical pulmonary hemorrhage requiring embolization and mechanical ventilation. Furthermore, the risk factors for occurrence of complications in BPA are unclear; therefore, this study aimed to evaluate predictors of procedural complications in BPA. METHODS In this retrospective study, we collected clinical data (patient characteristics, details of medical therapy, hemodynamic parameters, and details of the BPA procedure) from 321 consecutive sessions involving 81 patients who underwent BPA. Procedural complications were evaluated as endpoints. RESULTS BPA for residual PH after PEA was performed in 141 sessions (43.9 %), which involved 37 patients. Procedural complications were observed in 79 sessions (24.6 %), including severe pulmonary hemorrhage requiring embolization in 29 sessions (9.0 % of all sessions). No patients experienced severe complications requiring intubation with mechanical ventilation or extracorporeal membrane oxygenation. Age ≥ 75 years and mean pulmonary artery pressure ≥ 30 mmHg were independent predictors of procedural complications. Residual PH after PEA was a significant predictor of severe pulmonary hemorrhage requiring embolization (adjusted odds ratio, 3.048; 95 % confidence interval, 1.042-8.914, p = 0.042). CONCLUSIONS Older age, high pulmonary artery pressure, and residual PH after PEA increase the risk of severe pulmonary hemorrhage requiring embolization in BPA.
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Affiliation(s)
- Ryosuke Ito
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Jun Yamashita
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan.
| | - Sayo Ikeda
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yuki Nakajima
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Tomohiro Kasahara
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yuichi Sasaki
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Shun Suzuki
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Lisa Takahashi
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Ikki Komatsu
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Naotaka Murata
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Yusuke Shimahara
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University Hospital, Tokyo, Japan
| | - Taishiro Chikamori
- Department of Cardiology, Tokyo Medical University Hospital, Tokyo, Japan
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13
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Chan JCY, Man HSJ, Asghar UM, McRae K, Zhao Y, Donahoe LL, Wu L, Granton J, de Perrot M. Impact of sex on outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2023; 42:1578-1586. [PMID: 37422146 DOI: 10.1016/j.healun.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The impact of sex on long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (PH) remains unclear. We therefore examined the early and long-term outcome after PEA to determine whether sex had an impact on the risk of residual PH and need for targeted PH medical therapy. METHODS Retrospective study of 401 consecutive patients undergoing PEA at our institution between August 2005 and March 2020 was performed. Primary outcome was the need for targeted PH medical therapy postoperatively. Secondary outcomes included survival and measures of hemodynamic improvement. RESULTS Females (N = 203, 51%) were more likely to have preoperative home oxygen therapy (29.6% vs 11.6%, p < 0.01), and to present with segmental and subsegmental disease compared to males (49.2% vs 21.2%, p < 0.01). Despite similar preoperative values, females had higher postoperative pulmonary vascular resistance (final total pulmonary vascular resistance after PEA, 437 Dynes∙s∙cm-5 vs 324 Dynes∙s∙cm-5 in males, p < 0.01). Although survival at 10 years was not significantly different between sexes (73% in females vs 84% in males, p = 0.08), freedom from targeted PH medical therapy was lower in females (72.9% vs 89.9% in males at 5 years, p < 0.001). Female sex remained an independent factor affecting the need for targeted PH medical therapy after PEA in multivariate analysis (HR 2.03, 95%CI 1.03-3.98, p = 0.04). CONCLUSIONS Although outcomes are excellent for both sexes, females had greater need for targeted PH medical therapy in the long-term. Early reassessment and long-term follow-up of these patients are important. Further investigations into possible mechanisms to explain the differences are warranted.
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Affiliation(s)
- Justin C Y Chan
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - H S Jeffrey Man
- Department of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Usman M Asghar
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anaesthesia and Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Yidan Zhao
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Laura L Donahoe
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Licun Wu
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - John Granton
- Department of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada.
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14
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Guth S, Wilkens H, Halank M, Held M, Hobohm L, Konstantinides S, Omlor A, Seyfarth HJ, Schäfers HJ, Mayer E, Wiedenroth CB. [Chronic thromboembolic pulmonary hypertension]. Pneumologie 2023; 77:937-946. [PMID: 37963483 DOI: 10.1055/a-2145-4807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is an important late complication of acute pulmonary embolism, in which the thrombi transform into fibrous tissue, become integrated into the vessel wall, and lead to chronic obstructions. CTEPD is differentiated into cases without pulmonary hypertension (PH), characterized by a mean pulmonary arterial pressure up to 20 mmHg and a form with PH. Then, it is still referred to as chronic thromboembolic pulmonary hypertension (CTEPH).When there is suspicion of CTEPH, initial diagnostic tests should include echocardiography and ventilation/perfusion scan to detect perfusion defects. Subsequently, referral to a CTEPH center is recommended, where further imaging diagnostics and right heart catheterization are performed to determine the appropriate treatment.Currently, three treatment modalities are available. The treatment of choice is pulmonary endarterectomy (PEA). For non-operable patients or patients with residual PH after PEA, PH-targeted medical therapy, and the interventional procedure of balloon pulmonary angioplasty (BPA) are available. Increasingly, PEA, BPA, and pharmacological therapy are combined in multimodal concepts.Patients require post-treatment follow-up, preferably at (CTE)PH centers. These centers are required to perform a minimum number of PEA surgeries (50/year) and BPA interventions (100/year).
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Affiliation(s)
- Stefan Guth
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
| | - Heinrike Wilkens
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Michael Halank
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Deutschland
| | - Matthias Held
- Medizinische Klinik mit Schwerpunkt Pneumologie & Beatmungsmedizin, Missionsärztliche Klinik Würzburg, Würzburg, Deutschland
| | - Lukas Hobohm
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Stavros Konstantinides
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Mainz, Deutschland
| | - Albert Omlor
- Klinik für Innere Medizin 5, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Hans-Jürgen Seyfarth
- Bereich Pneumologie, Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Hans-Joachim Schäfers
- Klinik für Thorax-Herz-Gefäßchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Eckhard Mayer
- Abteilung für Thoraxchirurgie, Kerckhoff-Klinik GmbH, Bad Nauheim, Deutschland
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15
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Gopalan D, Riley JYJ, Leong K, Alsanjari S, Auger W, Lindholm P. Computed Tomography Pulmonary Angiography Prediction of Adverse Long-Term Outcomes in Chronic Thromboembolic Pulmonary Hypertension: Correlation with Hemodynamic Measurements Pre- and Post-Pulmonary Endarterectomy. Tomography 2023; 9:1787-1798. [PMID: 37888734 PMCID: PMC10611069 DOI: 10.3390/tomography9050142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 09/23/2023] [Accepted: 09/24/2023] [Indexed: 10/28/2023] Open
Abstract
CT pulmonary angiography is commonly used in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). This work was conducted to determine if cardiac chamber size on CTPA may also be useful for predicting the outcome of CTEPH treatment. A retrospective analysis of paired CTPA and right heart hemodynamics in 33 consecutive CTEPH cases before and after pulmonary thromboendarterectomy (PTE) was performed. Semiautomated and manual CT biatrial and biventricular size quantifications were correlated with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and cardiac output. The baseline indexed right atrioventricular volumes were twice the left atrioventricular volumes, with significant (p < 0.001) augmentation of left heart filling following PTE. Except for the left atrial volume to cardiac index, all other chamber ratios significantly correlated with hemodynamics. Left to right ventricular ratio cut point <0.82 has high sensitivity (91% and 97%) and specificity (88% and 85%) for identifying significant elevations of mPAP and PVR, respectively (AUC 0.90 and 0.95), outperforming atrial ratios (sensitivity 78% and 79%, specificity 82% and 92%, and AUC 0.86 and 0.91). Manual LV:RV basal dimension ratio correlates strongly with semiautomated volume ratio (r 0.77, 95% CI 0.64-0.85) and is an expeditious alternative with comparable prognostic utility (AUC 0.90 and 0.95). LV:RV dimension ratio of <1.03 and ≤0.99 (alternatively expressed as RV:LV ratio of >0.97 and ≥1.01) is a simple metric that can be used for CTEPH outcome prediction.
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Affiliation(s)
- Deepa Gopalan
- Department of Physiology and Pharmacology, Karolinska Institute, 171 77 Stockholm, Sweden;
- Department of Radiology, Imperial College Hospital NHS Trust, London W12 0HS, UK;
| | - Jan Y. J. Riley
- Department of Diagnostic Imaging, Monash Health, Melbourne 3168, Australia;
| | - Kai’en Leong
- Department of Cardiology, Royal Melbourne Hospital, Melbourne 3052, Australia;
| | - Senan Alsanjari
- Department of Radiology, Imperial College Hospital NHS Trust, London W12 0HS, UK;
| | - William Auger
- Department of Pulmonary Medicine, University of California, San Diego, CA 92037, USA;
| | - Peter Lindholm
- Department of Physiology and Pharmacology, Karolinska Institute, 171 77 Stockholm, Sweden;
- Department of Emergency Medicine, University of California, San Diego, CA 92103, USA
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16
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Allwood BW, Joubert L, Janson J. Chronic thromboembolic pulmonary hypertension: More options, more awareness. Afr J Thorac Crit Care Med 2023; 29:10.7196/AJTCCM.2023.v29i3.1496. [PMID: 37970577 PMCID: PMC10642392 DOI: 10.7196/ajtccm.2023.v29i3.1496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Affiliation(s)
- B W Allwood
- Division of Pulmonology, Department of Medicine, Faculty of Medicine and Health
Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - L Joubert
- Division of Cardiology, Department of Medicine, Faculty of Medicine and
Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town,
South Africa
| | - J Janson
- Division of Cardiothoracic Surgery, Department of Surgical Sciences, Faculty of
Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
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17
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Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
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18
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Ma J, Li C, Zhai Z, Zhen Y, Wang D, Liu M, Liu X, Duan J. Distribution of thrombus predicts severe reperfusion pulmonary edema after pulmonary endarterectomy. Asian J Surg 2023; 46:3766-3772. [PMID: 36997419 DOI: 10.1016/j.asjsur.2023.03.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 12/28/2022] [Accepted: 03/15/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVES Patients underwent pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to investigate the effect of thrombus distribution on the occurrence of severe reperfusion pulmonary edema (RPE) and identify specific parameters for predicting severe RPE. METHODS Patients with CTEPH who underwent PEA surgery were retrospectively analyzed. The thrombus in pulmonary arteries were evaluated through computed tomography pulmonary angiography. Based on presence of prolonged artificial ventilation, extracorporeal membrane oxygenation required, or perioperative death due to RPE, the patients were divided into the severe RPE and without severe RPE groups. MAIN RESULTS Among the 77 patients (29 women), 16 (20.8%) patients developed severe RPE. The right major pulmonary artery (RPA) (0.64[0.58, 0.73] vs 0.58[0.49, 0.64]; p = 0.008) and pulmonary artery trunk (PAT) thrombus ratios (0.48[0.44, 0.61] vs 0.42[0.39, 0.50]; p = 0.009) (the PAT ratio is expressed as the sum of the right middle lobe clot burden and right lower lobe clot burden divided by the total clot burden multiplied by 100) of the severe RPE group was significantly higher than that of the without severe RPE group. Receiver operator characteristics curve identified a PAT ratio of 43.4% as the threshold with areas under the curve = 0.71(95%CI 0.582; 0.841) for the development of severe RPE (sensitivity 0.875, specificity 0.541). The logistic regression analysis demonstrated that age, period from symptom onset to PEA, NT-pro BNP, preoperative mPAP, preoperative PVR, RPA ratio, and PAT ratio were associated with the development of severe RPE. Multivariable logistic regression analysis revealed PAT ratio (odds ratio = 10.2; 95% confidence interval 1.87, 55.53, P = 0.007) and period from symptom onset to PEA (OR = 1.01; 95% CI = 1.00-1.02, P = 0.015) as independent risk factors for the development of severe RPE. CONCLUSIONS The thrombus distribution could be a key factor in the severity of RPE. PAT ratio and medical history could predict the development of severe RPE.
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Affiliation(s)
- Junyu Ma
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Chen Li
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Zhenguo Zhai
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, National Clinical Research Center for Respiratory Diseases, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Dingyi Wang
- Department of Clinical research and Data management, Center of Respiratory Medicine, China-Japan Friendship Hospital; National Center for Respiratory Medicine; Institute of Respiratory Medicine, Chinese Academy of Medical Sciences; National Clinical Research Center for Respiratory Diseases, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Min Liu
- Department of Radiology, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China
| | - Jun Duan
- Surgical Intensive Care Unit, China-Japan Friendship Hospital, 2 Yinghua Dongjie, Chaoyang District, Beijing, 100029, China.
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Bird E, Hasenstab K, Kim N, Madani M, Malhotra A, Hahn L, Kligerman S, Hsiao A, Contijoch F. Mapping the Spatial Extent of Hypoperfusion in Chronic Thromboembolic Pulmonary Hypertension Using Multienergy CT. Radiol Cardiothorac Imaging 2023; 5:e220221. [PMID: 37693197 PMCID: PMC10483250 DOI: 10.1148/ryct.220221] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 06/05/2023] [Accepted: 07/03/2023] [Indexed: 09/12/2023]
Abstract
Purpose To assess if a novel automated method to spatially delineate and quantify the extent of hypoperfusion on multienergy CT angiograms can aid the evaluation of chronic thromboembolic pulmonary hypertension (CTEPH) disease severity. Materials and Methods Multienergy CT angiograms obtained between January 2018 and December 2020 in 51 patients with CTEPH (mean age, 47 years ± 17 [SD]; 27 women) were retrospectively compared with those in 110 controls with no imaging findings suggestive of pulmonary vascular abnormalities (mean age, 51 years ± 16; 81 women). Parenchymal iodine values were automatically isolated using deep learning lobar lung segmentations. Low iodine concentration was used to delineate areas of hypoperfusion and calculate hypoperfused lung volume (HLV). Receiver operating characteristic curves, correlations with preoperative and postoperative changes in invasive hemodynamics, and comparison with visual assessment of lobar hypoperfusion by two expert readers were evaluated. Results Global HLV correctly separated patients with CTEPH from controls (area under the receiver operating characteristic curve = 0.84; 10% HLV cutoff: 90% sensitivity, 72% accuracy, and 64% specificity) and correlated moderately with hemodynamic severity at time of imaging (pulmonary vascular resistance [PVR], ρ = 0.67; P < .001) and change after surgical treatment (∆PVR, ρ = -0.61; P < .001). In patients surgically classified as having segmental disease, global HLV correlated with preoperative PVR (ρ = 0.81) and postoperative ∆PVR (ρ = -0.70). Lobar HLV correlated moderately with expert reader lobar assessment (ρHLV = 0.71 for reader 1; ρHLV = 0.67 for reader 2). Conclusion Automated quantification of hypoperfused areas in patients with CTEPH can be performed from clinical multienergy CT examinations and may aid clinical evaluation, particularly in patients with segmental-level disease.Keywords: CT-Spectral Imaging (Multienergy), Pulmonary, Pulmonary Arteries, Embolism/Thrombosis, Chronic Thromboembolic Pulmonary Hypertension, Multienergy CT, Hypoperfusion© RSNA, 2023.
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Affiliation(s)
- Elizabeth Bird
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Kyle Hasenstab
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Nick Kim
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Michael Madani
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Atul Malhotra
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Lewis Hahn
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Seth Kligerman
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Albert Hsiao
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
| | - Francisco Contijoch
- From the Department of Bioengineering (E.B., A.H., F.C.), Department
of Radiology (K.H., L.H., S.K., A.H., F.C.), Department of Medicine, Division of
Pulmonary, Critical Care, and Sleep Medicine (N.K., A.M.), and Department of
Surgery (M.M.), University of California San Diego, 9500 Gilman Dr, MC 0412, La
Jolla, CA 92093
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20
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Fernandes TM, Kim NH, Kerr KM, Auger WR, Fedullo PF, Poch DS, Yang J, Papamatheakis DG, Alotaibi M, Bautista MA, Pretorius VG, Madani MM. Distal vessel pulmonary thromboendarterectomy: Results from a single institution. J Heart Lung Transplant 2023; 42:1112-1119. [PMID: 37024310 DOI: 10.1016/j.healun.2023.02.1500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries. METHODS Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group. RESULTS During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p = 0.039) and airway hemorrhage (3.0% vs 6.6%, p = 0.047) postoperatively. CONCLUSIONS Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.
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Affiliation(s)
- Timothy M Fernandes
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Nick H Kim
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Kim M Kerr
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - William R Auger
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Peter F Fedullo
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - David S Poch
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Jenny Yang
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California; San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Demosthenes G Papamatheakis
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Mona Alotaibi
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Marie A Bautista
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Victor G Pretorius
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Michael M Madani
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California.
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21
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Tsubata H, Nakanishi N, Itatani K, Takigami M, Matsubara Y, Ogo T, Fukuda T, Matsuda H, Matoba S. Pulmonary artery blood flow dynamics in chronic thromboembolic pulmonary hypertension. Sci Rep 2023; 13:6490. [PMID: 37081116 PMCID: PMC10119089 DOI: 10.1038/s41598-023-33727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/18/2023] [Indexed: 04/22/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension is caused by incomplete resolution and organization of thrombi. Blood flow dynamics are involved in thrombus formation; however, only a few studies have reported on pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension. Furthermore, the effects of treatment interventions on pulmonary artery blood flow dynamics are not fully understood. The aim of the study was to evaluate pulmonary artery blood flow dynamics in patients with chronic thromboembolic pulmonary hypertension before and after pulmonary endarterectomy and balloon pulmonary angioplasty, using computational fluid dynamics. We analyzed patient-specific pulmonary artery models of 10 patients with chronic thromboembolic pulmonary hypertension and three controls using computational fluid dynamics. In patients with chronic thromboembolic pulmonary hypertension, flow velocity and wall shear stress in the pulmonary arteries were significantly decreased, and the oscillatory shear index and blood stagnation volume were significantly increased than in controls. Pulmonary endarterectomy induced redistribution of pulmonary blood flow and improved blood flow dynamics in the pulmonary artery. Balloon pulmonary angioplasty improved pulmonary blood flow disturbance, decreased blood flow stagnation, and increased wall shear stress, leading to vasodilatation of the distal portion of the pulmonary artery following balloon pulmonary angioplasty treatment.
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Affiliation(s)
- Hideo Tsubata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan.
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Masao Takigami
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Yuki Matsubara
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tetsuya Fukuda
- Department of Radiology, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Hitoshi Matsuda
- Department of Vascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, 465 Kajii-cho Kawaramachi-Hirokoji, Kamigyo-ward, Kyoto, 602-8566, Japan
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22
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D'Armini AM, Pin M, Celentano A, Te Masiglat LJ, Borrelli E, Vanini B, Klersy C, Silvaggio G, Monterosso C, Alloni A, Pellegrini C, Ghio S. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: Relationship between treated branches and outcome. Int J Cardiol 2023; 377:124-130. [PMID: 36642333 DOI: 10.1016/j.ijcard.2023.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/12/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) it is important to minimize residual obstructions, in order to achieve low postoperative pulmonary vascular resistances and better clinical results. The aim of the study was to test the hypothesis that the greater the number of pulmonary artery branches treated at surgery, the better the hemodynamic and clinical outcome after PEA. METHODS In 564 consecutive CTEPH patients undergoing PEA the count of the number of treated branches was performed directly on the surgical specimens. Post-operative follow-up visits were scheduled at 3 months and 12 months after surgery including right heart catheterization and modified Bruce test. RESULTS The population was divided into tertiles based on the number of treated branches: Group 1 (from 4 to 30 treated branches, n = 194 patients); Group 2 (from 31 to 43 treated branches, n = 190 patients); Group 3 (from 44 to 100 treated branches, n = 180 patients). At 3 and at 12 months after PEA, after adjustment for confounders, patients in the highest tertile of treated branches had significantly lower values of pulmonary vascular resistance and higher values of pulmonary arterial compliance as compared to the other two groups (p < 0.002). Hospital mortality was 3% in Group 3, 6% in Group 2 and 10% in Group 1 (overall p = 0.035). CONCLUSIONS In CTEPH patients undergoing PEA, a higher number of treated pulmonary artery branches is associated with a better hemodynamic and a better clinical outcome at 3 months and 12 months after surgery.
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Affiliation(s)
- Andrea M D'Armini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Maurizio Pin
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Anna Celentano
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Leslie J Te Masiglat
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Ermelinda Borrelli
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Benedetta Vanini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Giuseppe Silvaggio
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Cristian Monterosso
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alessia Alloni
- Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Pellegrini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 1, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Ghio
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
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23
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Bhat SPS, Prasannakumar CS, Joshi T. Hydrodissection in chronic pulmonary endarterectomy. Indian J Thorac Cardiovasc Surg 2023; 39:211-215. [PMID: 36785600 PMCID: PMC9918635 DOI: 10.1007/s12055-023-01476-w] [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: 09/02/2022] [Revised: 01/03/2023] [Accepted: 01/04/2023] [Indexed: 01/26/2023] Open
Abstract
In our series of surgical pulmonary endarterectomies done for chronic thromboembolic pulmonary hypertension, we have incorporated the principle of hydrodissection with the aid of a carbon dioxide (CO2) mist blower which is routinely used for off-pump coronary artery bypass (OPCAB) surgeries. This added method of endarterectomy will help to achieve optimum clearance of thrombic load with basic cardiac surgical instruments. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-023-01476-w.
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Affiliation(s)
| | - Chirag Sumithra Prasannakumar
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
| | - Tejal Joshi
- Department of Cardiothoracic and Vascular Surgery, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
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24
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Update on the roles of imaging in the management of chronic thromboembolic pulmonary hypertension. J Cardiol 2023; 81:297-306. [PMID: 35490106 DOI: 10.1016/j.jjcc.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/02/2022] [Indexed: 02/01/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), classified as group 4 pulmonary hypertension (PH), is caused by stenosis and obstruction of the pulmonary arteries by organized thrombi that are incompletely resolved after acute pulmonary embolism. The prognosis of patients with CTEPH is poor if untreated; however, in expert centers with multidisciplinary teams, a treatment strategy for CTEPH has been established, dramatically improving its prognosis. CTEPH is currently not a fatal disease and is the only curable form of PH. Despite these advances and the establishment of treatment approaches, early diagnosis is still challenging, especially for non-experts, for several reasons. One of the reasons for this is insufficient knowledge of the various diagnostic imaging modalities, which are essential in the clinical practice of CTEPH. Imaging modalities should detect the following pathological findings: lung perfusion defects, thromboembolic lesions in pulmonary arteries, and right ventricular remodeling and dysfunction. Perfusion lung scintigraphy and catheter angiography have long been considered gold standards for the detection of perfusion defects and assessment of vascular lesions, respectively. However, advances in imaging technology of computed tomography and magnetic resonance imaging have enabled the non-invasive detection of these abnormal findings in a single examination. Cardiac magnetic resonance (CMR) is the gold standard for evaluating the morphology and function of the right heart; however, state-of-the-art techniques in CMR allow the assessment of cardiac tissue characterization and hemodynamics in the pulmonary arteries. Comprehensive knowledge of the role of imaging in CTEPH enables appropriate use of imaging modalities and accurate image interpretation, resulting in early diagnosis, determination of treatment strategies, and appropriate evaluation of treatment efficacy. This review summarizes the current roles of imaging in the clinical practice for CTEPH, demonstrating the characteristic findings observed in each modality.
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Nishihara T, Shimokawahara H, Ogawa A, Naito T, Une D, Mukai T, Niiya H, Ito H, Matsubara H. Comparison of the safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with surgically accessible and inaccessible lesions. J Heart Lung Transplant 2023; 42:786-794. [PMID: 36792382 DOI: 10.1016/j.healun.2023.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 11/27/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Although pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension, not all patients are eligible. While balloon pulmonary angioplasty is an alternative for such patients, its efficacy and safety may differ between patients with and without surgically accessible lesions. METHODS This study involved 344 patients treated with balloon pulmonary angioplasty who were ineligible for pulmonary endarterectomy. Based on the angiographical lesion location, patients were divided into the surgically accessible (Group 1) and inaccessible (Group 2) groups, and percent changes in hemodynamics and clinical parameters before and after balloon pulmonary angioplasty were investigated. We also conducted survival analyses using Kaplan-Meier analysis. RESULTS While no differences in baseline characteristics were identified between the groups, balloon pulmonary angioplasty significantly improved hemodynamics in both groups, without any difference regarding the incidence of complications. Meanwhile, the percent changes in the mean pulmonary arterial pressure, pulmonary vascular resistance, 6-min walk distance, right ventricular area index on echocardiography, and the achievement rate of World Health Organization functional class I after balloon pulmonary angioplasty were significantly lower in Group 1 than in Group 2. The cumulative survival rates at 1, 5, and 10 years after balloon pulmonary angioplasty were not significantly different between the two groups (Group 1: 92.5%, 86.1%, 84.3%; and Group 2: 96.5%, 92.9%, 90.1%, respectively). CONCLUSIONS The outcome of balloon pulmonary angioplasty in inoperable patients with surgically accessible proximal lesions was acceptable; however, further investigations are necessary to clarify the optimal treatment for such patients.
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Affiliation(s)
- Takahiro Nishihara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan; Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiroto Shimokawahara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan.
| | - Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takanori Naito
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Dai Une
- Department of Cardiovascular surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takashi Mukai
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Harutaka Niiya
- Department of Radiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Hiroshi Ito
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, Okayama, Japan
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26
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Dubs L, Ulrich S, Lichtblau M, Opitz I. [Pulmonary Endarterectomy and Treatment for Chronic Thromboembolic Pulmonary Hypertension]. PRAXIS 2023; 112:28-35. [PMID: 36597683 DOI: 10.1024/1661-8157/a003964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Pulmonary Endarterectomy and Treatment for Chronic Thromboembolic Pulmonary Hypertension Abstract. Chronic thromboembolic pulmonary hypertension is a relatively rare disease which mostly evolves as a complication of acute pulmonary embolism resulting from the fibrotic organization of residual thrombotic material despite adequate anticoagulation leading to precapillary pulmonary hypertension and persistence of its symptoms. The elevated pulmonary vascular resistance leads to right ventricular heart failure, its symptoms and reduced prognosis. The therapy of choice is the pulmonary endarterectomy, which leads to a reduction of symptoms, optimization of the hemodynamics and improved prognosis. Misdiagnosis and delayed referral often lead to disease progression along with poor surgical outcome. In case of more distal, surgically non-accessible disease, treatment consists of balloon pulmonary angioplasty and pulmonary vasodilator drugs.
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Affiliation(s)
- Linus Dubs
- Klinik für Thoraxchirurgie, Universitätsspital Zürich, Zürich, Schweiz
| | - Silvia Ulrich
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Mona Lichtblau
- Klinik für Pneumologie, Universitätsspital Zürich, Zürich, Schweiz
| | - Isabelle Opitz
- Klinik für Thoraxchirurgie, Universitätsspital Zürich, Zürich, Schweiz
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Song W, Zhu J, Zhong Z, Song Y, Liu S. Long-term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy. Clin Cardiol 2022; 45:1255-1263. [PMID: 36070474 DOI: 10.1002/clc.23900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 07/25/2022] [Accepted: 08/01/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), which has good long-term outcomes. However, after surgery, a quarter of the patients still have residual pulmonary hypertension (RPH). In pulmonary hemodynamics, there are no unified criteria for RPH, even though the level may affect long-term survival. METHODS Between March 1997 and December 2021, 253 CTEPH patients were treated at our center with PEA. Patients were evaluated retrospectively and classified into early (1997-2014) and late (2015-2021) groups. The clinical characteristics and perioperative outcomes of the two groups were compared, and risk factor analysis for RPH and long-term survival for all cases was performed. RESULTS There was no statistically significant difference in demographics between the two groups. However, the Early Group had a significantly higher rate of perioperative death (9.8% vs. 1.2%, p = .001), RPH (48.8% vs. 14.0%, p < .001), and reperfusion pulmonary edema (18.3% vs. 2.9%, p < .001). The median follow-up time was 66.0 months, and overall survival rates at 5, 10, 15, and 18 years after PEA were 91.2%, 83.9%, 64.5%, and 46.0%, respectively. Age and postoperative systolic pulmonary artery pressure (sPAP) were independently related to long-term outcomes in the multivariate Cox analyses. Patients with postoperative sPAP less than 46 mm Hg had a higher chance of survival. CONCLUSIONS PEA improved CTEPH hemodynamics immediately and had a positive effect on long-term survival. Patients with postoperative sPAP ≥ 46 mm Hg indicate clinically significant RPH and have a lower long-term survival rate.
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Affiliation(s)
- Wu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiade Zhu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - ZhaoJi Zhong
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yunhu Song
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sheng Liu
- Department of Cardiac Surgery, Key Laboratory of Pulmonary Vascular Medicine, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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Zhao M, Nie P, Guo Y, Chen H. Pulmonary artery intimal sarcoma: A rare cause of filling defects in pulmonary arteries. Am J Med Sci 2022; 364:655-660. [PMID: 35588894 DOI: 10.1016/j.amjms.2022.05.009] [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: 03/04/2021] [Revised: 10/07/2021] [Accepted: 05/11/2022] [Indexed: 01/25/2023]
Abstract
Pulmonary artery intimal sarcomas are very rare and arise from primitive pluripotent mesenchymal cells. They are often misdiagnosed as pulmonary thromboembolism, leading to futile anticoagulation treatment and delayed diagnosis. We present a case of a patient who showed nonspecific pulmonary symptoms and characteristic imaging manifestation. Progressive symptoms and additional imaging led to the suspicion of a pulmonary artery intimal sarcoma, which was finally confirmed by pathological biopsy. This case serves as a reminder to consider pulmonary artery intimal sarcomas in the differential diagnosis of patients with dyspnea and filling defects on computed tomography pulmonary angiography or contrast-enhanced computed tomography.
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Affiliation(s)
- Mimi Zhao
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China, 266003
| | - Pei Nie
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China, 266003
| | - Yonghua Guo
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China, 266003
| | - Haisong Chen
- Department of Radiology, The Affiliated Hospital of Qingdao University, Qingdao, China, 266003.
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Harvey JJ, Huang S, Uberoi R. Catheter-directed therapies for the treatment of high risk (massive) and intermediate risk (submassive) acute pulmonary embolism. Cochrane Database Syst Rev 2022; 8:CD013083. [PMID: 35938605 PMCID: PMC9358724 DOI: 10.1002/14651858.cd013083.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute pulmonary embolism (APE) is a major cause of acute morbidity and mortality. APE results in long-term morbidity in up to 50% of survivors, known as post-pulmonary embolism (post-PE) syndrome. APE can be classified according to the short-term (30-day) risk of mortality, based on a variety of clinical, imaging and laboratory findings. Most mortality and morbidity is concentrated in high-risk (massive) and intermediate-risk (submassive) APE. The first-line treatment for APE is systemic anticoagulation. High-risk (massive) APE accounts for less than 10% of APE cases and is a life-threatening medical emergency, requiring immediate reperfusion treatment to prevent death. Systemic thrombolysis is the recommended treatment for high-risk (massive) APE. However, only a minority of the people affected receive systemic thrombolysis, due to comorbidities or the 10% risk of major haemorrhagic side effects. Of those who do receive systemic thrombolysis, 8% do not respond in a timely manner. Surgical pulmonary embolectomy is an alternative reperfusion treatment, but is not widely available. Intermediate-risk (submassive) APE represents 45% to 65% of APE cases, with a short-term mortality rate of around 3%. Systemic thrombolysis is not recommended for this group, as major haemorrhagic complications outweigh the benefit. However, the people at higher risk within this group have a short-term mortality of around 12%, suggesting that anticoagulation alone is not an adequate treatment. Identification and more aggressive treatment of people at intermediate to high risk, who have a more favourable risk profile for reperfusion treatments, could reduce short-term mortality and potentially reduce post-PE syndrome. Catheter-directed treatments (catheter-directed thrombolysis and catheter embolectomy) are minimally invasive reperfusion treatments for high- and intermediate-risk APE. Catheter-directed treatments can be used either as the primary treatment or as salvage treatment after failure of systemic thrombolysis. Catheter-directed thrombolysis administers 10% to 20% of the systemic thrombolysis dose directly into the thrombus in the lungs, potentially reducing the risks of haemorrhagic side effects. Catheter embolectomy mechanically removes the thrombus without the need for thrombolysis, and may be useful for people with contraindications for thrombolysis. Currently, the benefits of catheter-based APE treatments compared with existing medical and surgical treatment are unclear despite increasing adoption of catheter treatments by PE response teams. This review examines the evidence for the use of catheter-directed treatments in high- and intermediate-risk APE. This evidence could help guide the optimal treatment strategy for people affected by this common and life-threatening condition. OBJECTIVES To assess the effects of catheter-directed therapies versus alternative treatments for high-risk (massive) and intermediate-risk (submassive) APE. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search was 15 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) of catheter-directed therapies for the treatment of high-risk (massive) and intermediate-risk (submassive) APE. We excluded catheter-directed treatments for non-PE. We applied no restrictions on participant age or on the date, language or publication status of RCTs. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. The main outcomes were all-cause mortality, treatment-associated major and minor haemorrhage rates based on two established clinical definitions, recurrent APE requiring retreatment or change to a different APE treatment, length of hospital stay, and quality of life. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We identified one RCT (59 participants) of (ultrasound-augmented) catheter-directed thrombolysis for intermediate-risk (submassive) APE. We found no trials of any catheter-directed treatments (thrombectomy or thrombolysis) in people with high-risk (massive) APE or of catheter-based embolectomy in people with intermediate-risk (submassive) APE. The included trial compared ultrasound-augmented catheter-directed thrombolysis with alteplase and systemic heparinisation versus systemic heparinisation alone. In the treatment group, each participant received an infusion of alteplase 10 mg or 20 mg over 15 hours. We identified a high risk of selection and performance bias, low risk of detection and reporting bias, and unclear risk of attrition and other bias. Certainty of evidence was very low because of risk of bias and imprecision. By 90 days, there was no clear difference in all-cause mortality between the treatment group and control group. A single death occurred in the control group at 20 days after randomisation, but it was unrelated to the treatment or to APE (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.01 to 7.96; 59 participants). By 90 days, there were no episodes of treatment-associated major haemorrhage in either the treatment or control group. There was no clear difference in treatment-associated minor haemorrhage between the treatment and control group by 90 days (OR 3.11, 95% CI 0.30 to 31.79; 59 participants). By 90 days, there were no episodes of recurrent APE requiring retreatment or change to a different APE treatment in the treatment or control group. There was no clear difference in the length of mean total hospital stay between the treatment and control groups. Mean stay was 8.9 (standard deviation (SD) 3.4) days in the treatment group versus 8.6 (SD 3.9) days in the control group (mean difference 0.30, 95% CI -1.57 to 2.17; 59 participants). The included trial did not investigate quality of life measures. AUTHORS' CONCLUSIONS: There is a lack of evidence to support widespread adoption of catheter-based interventional therapies for APE. We identified one small trial showing no clear differences between ultrasound-augmented catheter-directed thrombolysis with alteplase plus systemic heparinisation versus systemic heparinisation alone in all-cause mortality, major and minor haemorrhage rates, recurrent APE and length of hospital stay. Quality of life was not assessed. Multiple small retrospective case series, prospective patient registries and single-arm studies suggest potential benefits of catheter-based treatments, but they provide insufficient evidence to recommend this approach over other evidence-based treatments. Researchers should consider clinically relevant primary outcomes (e.g. mortality and exercise tolerance), rather than surrogate markers (e.g. right ventricular to left ventricular (RV:LV) ratio or thrombus burden), which have limited clinical utility. Trials must include a control group to determine if the effects are specific to the treatment.
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Affiliation(s)
- John J Harvey
- Trinity College, University of Oxford, Oxford, UK
- Department of Radiology, Royal Children's Hospital Melbourne, Parkville, Australia
| | - Shiwei Huang
- Department of Radiology, St George Hospital, Kogarah, Australia
| | - Raman Uberoi
- Department of Radiology, John Radcliffe NHS Trust Hospital, Oxford, UK
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Fernandes CJCDS, Ota-Arakaki JS, Campos FTAF, Correa RDA, Gazzana MB, Jardim CVP, Jatene FB, Alves JL, Ramos RP, Tannus D, Teles C, Terra M, Waetge D, Souza R. Brazilian Thoracic Society recommendations for the diagnosis and treatment of chronic thromboembolic pulmonary hypertension. J Bras Pneumol 2022; 46:e20200204. [PMID: 35766678 PMCID: PMC9233986 DOI: 10.36416/1806-3756/e20200204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious and debilitating disease caused by occlusion of the pulmonary arterial bed by hematic emboli and by the resulting fibrous material. Such occlusion increases vascular resistance and, consequently, the pressure in the region of the pulmonary artery, which is the definition of pulmonary hypertension. The increased load imposed on the right ventricle leads to its progressive dysfunction and, finally, to death. However, CTEPH has a highly significant feature that distinguishes it from other forms of pulmonary hypertension: the fact that it can be cured through treatment with pulmonary thromboendarterectomy. Therefore, the primary objective of the management of CTEPH should be the assessment of patient fitness for surgery at a referral center, given that not all patients are good candidates. For the patients who are not good candidates for pulmonary thromboendarterectomy, the viable therapeutic alternatives include pulmonary artery angioplasty and pharmacological treatment. In these recommendations, the pathophysiological bases for the onset of CTEPH, such as acute pulmonary embolism and the clinical condition of the patient, will be discussed, as will the diagnostic algorithm to be followed and the therapeutic alternatives currently available.
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Affiliation(s)
- Caio Julio Cesar dos Santos Fernandes
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Jaquelina Sonoe Ota-Arakaki
- . Disciplina de Pneumologia. Hospital São Paulo, Escola Paulista de Medicina. Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | | | - Ricardo de Amorim Correa
- . Serviço de Pneumologia e Cirurgia Torácica, Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte (MG) Brasil
| | - Marcelo Basso Gazzana
- . Serviço de Pneumologia, Hospital de Clínicas de Porto Alegre, Porto Alegre (RS) Brasil
| | - Carlos Vianna Poyares Jardim
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Fábio Biscegli Jatene
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Jose Leonidas Alves
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Roberta Pulcheri Ramos
- . Disciplina de Pneumologia. Hospital São Paulo, Escola Paulista de Medicina. Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Daniela Tannus
- . Hospital das Clínicas, Faculdade de Medicina, Universidade Federal de Goiás, Goiânia (GO) Brasil
| | - Carlos Teles
- . Disciplina de Pneumologia. Hospital São Paulo, Escola Paulista de Medicina. Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Mario Terra
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Daniel Waetge
- . Disciplina de Pneumologia, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro (RJ) Brasil
| | - Rogerio Souza
- . Grupo de Circulação Pulmonar, Divisão de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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McGlothlin D, Granton J, Klepetko W, Beghetti M, Rosenzweig EB, Corris P, Horn E, Kanwar M, McRae K, Roman A, Tedford R, Badagliacca R, Bartolome S, Benza R, Caccamo M, Cogswell R, Dewachter C, Donahoe L, Fadel E, Farber HW, Feinstein J, Franco V, Frantz R, Gatzoulis M, Hwa (Anne) Goh C, Guazzi M, Hansmann G, Hastings S, Heerdt P, Hemnes A, Herpain A, Hsu CH, Kerr K, Kolaitis N, Kukreja J, Madani M, McCluskey S, McCulloch M, Moser B, Navaratnam M, Radegran G, Reimer C, Savale L, Shlobin O, Svetlichnaya J, Swetz K, Tashjian J, Thenappan T, Vizza CD, West S, Zuckerman W, Zuckermann A, De Marco T. ISHLT CONSENSUS STATEMENT: Peri-operative Management of Patients with Pulmonary Hypertension and Right Heart Failure Undergoing Surgery. J Heart Lung Transplant 2022; 41:1135-1194. [DOI: 10.1016/j.healun.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 10/17/2022] Open
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Simakova MA, Zlobina IS, Berezina AV, Marukyan NV, Osadchii AM, Zugurov IK, Gordeev ML, Moiseeva OM. Cardiopulmonary exercise testing for treatment effect assessment in chronic thromboembolic pulmonary hypertension patients. KARDIOLOGIIA 2022; 62:44-54. [PMID: 35569163 DOI: 10.18087/cardio.2022.4.n1611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 05/02/2021] [Accepted: 05/28/2021] [Indexed: 06/15/2023]
Abstract
Aim To determine possibilities of the cardiopulmonary stress test (CPST) as an unbiassed, noninvasive method for evaluation of the effect of managing patients with chronic thromboembolic pulmonary hypertension (CTEPH).Material and methods This study included 37 patients with CTEPH, 24 men (mean age, 53±15 years) and 13 women (mean age, 58±8.5 years). The diagnosis was verified and theCoperability was assessed according to 2015 European Society of Cardiology Clinical Guidelines for the Diagnosis and Treatment of Pulmonary Hypertension (PH). The surgical treatment was used in 65 % (n=24) of CTEPH patients: the group with pulmonary thromboendarterectomy constituted 35 % (n=13); the group with balloon pulmonary angioplasty 30% (n=11); and the conservative tactics was used in 27 % (n=10) of patients.Results Baseline CPST parameters significantly correlated with parameters of right heart catheterization (RHC): mixed venous oxygen saturation (SvO2) significantly positively correlated with V´O2peak (r=0.640, p<0.05), V´O2 / heart rate (HR) (r=0.557; p<0.001), PETCO2 peak (r=0.598, p<0.05), and V´E / V´CO2 (r=0.587; p<0.001); cardiac output (CO) correlated with V´O2 / HR (r=0.555, p<0.001), PETCO2peak (r= -0.476; p<0.05 and r=0.555, p<0.001 for ´E / V´CO2). In repeated testing, the physical working capacity (V´O2peak) increased only in patients after the surgical treatment of CTEPH. Importantly in this process, significant correlations remained between a number of CPST and RHC parameters: SvO2 correlated with V´O2peak (r=0.743; p<0.05), V´O2 /HR (r=0.627; p<0.001), PETCO2peak (r=0.538; p<0.05), and V´E / V´CO2 (r=0.597; p<0.001); V´O2 / HR, PETCO2peak, and V´E / V´CO2 significantly correlated with CO (r=0.645, p<0.001; r= -0.516, p<0.001, and r=0.555, p<0.001, respectively.Conclusion CPST can be used as a noninvasive instrument for evaluation of the effect of CTEPH treatment, particularly in the absence of echocardiographic data for residual PH.
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Affiliation(s)
- M A Simakova
- Almazov National Medical Research Centre, Saint-Petersburg
| | - I S Zlobina
- Almazov National Medical Research Centre, Saint-Petersburg
| | - A V Berezina
- Almazov National Medical Research Centre, Saint-Petersburg
| | - N V Marukyan
- Almazov National Medical Research Centre, Saint-Petersburg
| | - A M Osadchii
- Almazov National Medical Research Centre, Saint-Petersburg
| | - I K Zugurov
- Almazov National Medical Research Centre, Saint-Petersburg
| | - M L Gordeev
- Almazov National Medical Research Centre, Saint-Petersburg
| | - O M Moiseeva
- Almazov National Medical Research Centre, Saint-Petersburg
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Forfia P, Ferraro B, Vaidya A. Recognizing Pulmonary Hypertension Following Pulmonary Thromboendarterectomy
A Practical Guide for Clinicians. Pulm Circ 2022; 12:e12073. [DOI: 10.1002/pul2.12073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 03/01/2022] [Accepted: 03/13/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Paul Forfia
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Bruce Ferraro
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
| | - Anjali Vaidya
- Pulmonary Hypertension, Right Heart Failure, and CTEPH Program; Heart and Vascular Institute Temple University Lewis Katz School of Medicine Philadelphia PA USA
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Martin-Suarez S, Loforte A, Cavalli GG, Gliozzi G, Botta L, Mariani C, Orioli V, Votano D, Costantino A, Santamaria V, Tassi S, Fiaschini C, Campanini F, Palazzini M, Rossi B, Barbera NA, Niro F, Manes A, Saia F, Dardi F, Galiè N, Pacini D. Therapeutic alternatives in chronic thromboembolic pulmonary hypertension: from pulmonary endarterectomy to balloon pulmonary angioplasty to medical therapy. State of the art from a multidisciplinary team. Ann Cardiothorac Surg 2022; 11:120-127. [PMID: 35433353 PMCID: PMC9012190 DOI: 10.21037/acs-2021-pte-23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/02/2022] [Indexed: 08/26/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease with a very complex pathophysiology differing from other causes of pulmonary hypertension (PH). It is an infrequent consequence of acute pulmonary embolism that is frequently misdiagnosed. Pathogenesis has been related to coagulation abnormalities, infection or inflammation, although these disturbances can be absent in many cases. The hallmarks of CTEPH are thrombotic occlusion of pulmonary vessels, variable degree of ventricular dysfunction and secondary microvascular arteriopathy. The definition of CTEPH also includes an increase in mean pulmonary arterial pressure of more than 25 mmHg with a normal pulmonary capillary wedge of less than 15 mmHg. It is classified as World Health Organization group 4 PH, and is the only type that can be surgically cured by pulmonary endarterectomy (PEA). This operation needs to be carried out by a team with strong expertise, from the diagnostic and decisional pathway to the operation itself. However, because the disease has a very heterogeneous phenotype in terms of anatomy, degree of PH and the lack of a standard patient profile, not all cases of CTEPH can be treated by PEA. As a result, PH-directed medical therapy traditionally used for the other types of PH has been proposed and is utilized in CTEPH patients. Since 2015, we have been witnessing the rebirth of balloon pulmonary angioplasty, a technique first performed in 2001 but has since fallen out fashion due to major complications. The refinement of such techniques has allowed its safe utilization as a salvage therapy in inoperable patients. In the present keynote lecture, we will describe these therapeutic approaches and results.
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Affiliation(s)
- Sofia Martin-Suarez
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonio Loforte
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Giulio Giovanni Cavalli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Gregorio Gliozzi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Luca Botta
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Carlo Mariani
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valentina Orioli
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Daniela Votano
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Antonino Costantino
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Valeria Santamaria
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Sara Tassi
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Costanza Fiaschini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Campanini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Massimiliano Palazzini
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Barbara Rossi
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nicolò Antonino Barbera
- Cardiac Anaesthesia Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Niro
- Cardiovascular Radiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Alessandra Manes
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Fabio Dardi
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
| | - Davide Pacini
- Cardiac Surgery Unit, Cardio Thoracic and Vascular Department, S.Orsola Hospital IRCCS, Bologna University, Bologna, Italy
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de Perrot M, Donahoe L, McRae K, Thenganatt J, Moric J, Chan J, McInnis M, Jumaa K, Tan KT, Mafeld S, Granton J, Weatherald J, Hirani N, Thakrar M, Helmersen D, Swiston J, Brunner N, Levy R, Mehta S, Kapasi A, Lien D, Michelakis E, Hernandez P, Kemp K, Hirsch A, Langleben D, Hambly N, Dorasamy P, D'Arsigny C, Chandy G, Mielniczuk LM, Christiansen D, Fox G, Laframboise K, Provencher S. Outcome After Pulmonary Endarterectomy For Segmental Chronic Thromboembolic Pulmonary Hypertension. J Thorac Cardiovasc Surg 2022; 164:696-707.e4. [DOI: 10.1016/j.jtcvs.2021.10.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
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Verbelen T, Godinas L, Maleux G, Coolen J, Claessen G, Belge C, Meyns B, Delcroix M. Chronic thromboembolic pulmonary hypertension: diagnosis, operability assessment and patient selection for pulmonary endarterectomy. Ann Cardiothorac Surg 2022; 11:82-97. [PMID: 35433370 PMCID: PMC9012197 DOI: 10.21037/acs-2021-pte-12] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 07/30/2023]
Abstract
Healthcare providers outside pulmonary hypertension (PH) centers having misinformation or insufficient education, and a general lack of treatment awareness contribute to a massive underdiagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), diagnostic delay and refusal of surgery by patients. Together with the subjective operability assessment, this leads to too few patients undergoing pulmonary endarterectomy (PEA); even though this surgery results in improved survival and exercise capacity. Acute pulmonary embolism (PE) survivors should undergo a CTEPH screening strategy. Patients screened positive and those with CTEPH symptoms (with or without history of PE), should undergo transthoracic echocardiography (TTE) to determine the probability of PH. High PH probability patients should undergo a ventilation/perfusion (V/Q) scan. A negative scan rules out CTEPH. Patients with a positive V/Q scan, but also patients with findings suggestive for CTEPH on computed tomography pulmonary angiography (CTPA) to diagnose acute PE, should be referred to a CTEPH center. Further diagnostic work-up currently consists of catheter based pulmonary angiography, CTPA and right heart catheterization. However, new imaging technologies might replace them in the near future, with one single imaging tool to screen, diagnose and assess operability as the ultimate goal. Operability assessment should be performed by a multidisciplinary CTEPH team. PEA surgery should be organized in a single center per country or for each forty to fifty million inhabitants in order to offer the highest level of expertise. Informing patients about PEA should preferably be done by the treating surgeon. Based on the estimated incidence of CTEPH and with a better education of patients and healthcare providers, despite the advent of new interventional and medical therapies for CTEPH, the number of PEA surgeries performed should still have the potential to grow significantly.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurent Godinas
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Coolen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Catharina Belge
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
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Tzoumas A, Peppas S, Sagris M, Papanastasiou CA, Barakakis PA, Bakoyiannis C, Taleb A, Kokkinidis DG, Giannakoulas G. Advances in treatment of chronic thromboembolic pulmonary hypertension. Thromb Res 2022; 212:30-37. [DOI: 10.1016/j.thromres.2022.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/20/2022] [Accepted: 02/02/2022] [Indexed: 01/29/2023]
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Surgical Management of Chronic Thromboembolic Pulmonary Hypertension. Cardiol Clin 2022; 40:89-101. [PMID: 34809920 PMCID: PMC8720361 DOI: 10.1016/j.ccl.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive disease, which may lead to severe right ventricular dysfunction and debilitating symptoms. Pulmonary thromboendarterectomy (PTE) provides the best opportunity for complete resolution of obstructing thromboembolic disease and functional improvement in appropriately selected patients. In this article, the authors review preoperative workup, patient selection, operative technique, postoperative care, and outcomes after PTE.
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Osman B, Bou Akel I, Tulimat T, Sfeir P, Borgi J. Initiating a Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy Program Based on a Single Center Experience in Lebanon. Semin Cardiothorac Vasc Anesth 2022; 26:187-194. [DOI: 10.1177/10892532211066645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose In 2018, the American University of Beirut Medical Center established the first multidisciplinary Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Endarterectomy program in Lebanon. The study describes the challenges faced in establishing the program and in improving patient referral, evaluation, and perioperative care. Methods The program establishment including the preparation phase, clinical evaluation, and team education is discussed. The implementation of the flow of patients referred to the program was established. Education regarding diagnosis and referral were provided to physicians in the community. The initial experience is described in a retrospective analysis of 4 consecutive patients who were diagnosed with CTEPH and underwent PEA. Results Four patients were diagnosed with CTEPH had PEA performed. The mean age of patients was 64 years. The average CPB and total circulatory arrest times were 244 and 23.9 minutes per side, respectively. No mortalities were encountered perio-operatively. All patients reported significant improvement in functional capacity from NYHA III and IV to a NYHA class of I with an average PASP decrease of 59.5 ± 19.7 mmHg and mPAP drop by 30.2 ± 16.3 mmHg. Conclusion The launch of the first CTEPH and PEA program in Lebanon, with a clear framework, coupled with good surgical outcomes is very encouraging. The program offers a curative solution for CTEPH patients in the region. A clear referral process and an increase in disease and treatment awareness in the community are crucial to the future success of the program, offering a definitive treatment, and avoiding delays to surgery.
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Affiliation(s)
| | | | | | | | - Jamil Borgi
- American University of Beirut, Beirut, Lebanon
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40
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Eberhard M, McInnis M, de Perrot M, Lichtblau M, Ulrich S, Inci I, Opitz I, Frauenfelder T. Dual-Energy CT Pulmonary Angiography for the Assessment of Surgical Accessibility in Patients with Chronic Thromboembolic Pulmonary Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12020228. [PMID: 35204319 PMCID: PMC8870807 DOI: 10.3390/diagnostics12020228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 01/14/2022] [Accepted: 01/16/2022] [Indexed: 12/04/2022] Open
Abstract
We assessed the value of dual-energy CT pulmonary angiography (CTPA) for classification of the level of disease in chronic thromboembolic pulmonary hypertension (CTEPH) patients compared to the surgical Jamieson classification and prediction of hemodynamic changes after pulmonary endarterectomy. Forty-three CTEPH patients (mean age, 57 ± 16 years; 18 females) undergoing CTPA prior to surgery were retrospectively included. “Proximal” and “distal disease” were defined as L1 and 2a (main and lobar pulmonary artery [PA]) and L2b-4 (lower lobe basal trunk to subsegmental PA), respectively. Three radiologists had a moderate interobserver agreement for the radiological classification of disease (k = 0.55). Sensitivity was 92–100% and specificity was 24–53% to predict proximal disease according to the Jamieson classification. A median of 9 segments/patient had CTPA perfusion defects (range, 2–18 segments). L1 disease had a greater decrease in the mean pulmonary artery pressure (p = 0.029) and pulmonary vascular resistance (p = 0.011) after surgery compared to patients with L2a to L3 disease. The extent of perfusion defects was not associated with the level of disease or hemodynamic changes after surgery (p > 0.05 for all). CTPA is highly sensitive for predicting the level of disease in CTEPH patients with a moderate interobserver agreement. The radiological level of disease is associated with hemodynamic improvement after surgery.
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Affiliation(s)
- Matthias Eberhard
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, 8091 Zurich, Switzerland;
- Radiology, Spitäler fmi AG, 3800 Interlaken, Switzerland
- Correspondence: ; Tel.: +41-44-255-2900; Fax: +41-44-255-1819
| | - Micheal McInnis
- Joint Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W5, Canada;
| | - Marc de Perrot
- Division of Thoracic Surgery, Princess Margaret Cancer Centre (Toronto General Hospital), University Health Network, Toronto, ON M5G 2A2, Canada;
| | - Mona Lichtblau
- Department of Pulmonology Zurich, University Hospital Zurich, 8091 Zurich, Switzerland; (M.L.); (S.U.)
| | - Silvia Ulrich
- Department of Pulmonology Zurich, University Hospital Zurich, 8091 Zurich, Switzerland; (M.L.); (S.U.)
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland; (I.I.); (I.O.)
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, 8091 Zurich, Switzerland; (I.I.); (I.O.)
| | - Thomas Frauenfelder
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, 8091 Zurich, Switzerland;
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Mendelson AA, Rajaram A, Bainbridge D, Lawrence KS, Bentall T, Sharpe M, Diop M, Ellis CG. Dynamic tracking of microvascular hemoglobin content for continuous perfusion monitoring in the intensive care unit: pilot feasibility study. J Clin Monit Comput 2021; 35:1453-1465. [PMID: 33104968 PMCID: PMC7586414 DOI: 10.1007/s10877-020-00611-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 10/20/2020] [Indexed: 12/25/2022]
Abstract
PURPOSE There is a need for bedside methods to monitor oxygen delivery in the microcirculation. Near-infrared spectroscopy commonly measures tissue oxygen saturation, but does not reflect the time-dependent variability of microvascular hemoglobin content (MHC) that attempts to match oxygen supply with demand. The objective of this study is to determine the feasibility of MHC monitoring in critically ill patients using high-resolution near-infrared spectroscopy to assess perfusion in the peripheral microcirculation. METHODS Prospective observational cohort of 36 patients admitted within 48 h at a tertiary intensive care unit. Perfusion was measured on the quadriceps, biceps, and/or deltoid, using the temporal change in optical density at the isosbestic wavelength of hemoglobin (798 nm). Continuous wavelet transform was applied to the hemoglobin signal to delineate frequency ranges corresponding to physiological oscillations in the cardiovascular system. RESULTS 31/36 patients had adequate signal quality for analysis, most commonly affected by motion artifacts. MHC signal demonstrates inter-subject heterogeneity in the cohort, indicated by different patterns of variability and frequency composition. Signal characteristics were concordant between muscle groups in the same patient, and correlated with systemic hemoglobin levels and oxygen saturation. Signal power was lower for patients receiving vasopressors, but not correlated with mean arterial pressure. Mechanical ventilation directly impacts MHC in peripheral tissue. CONCLUSION MHC can be measured continuously in the ICU with high-resolution near-infrared spectroscopy, and reflects the dynamic variability of hemoglobin distribution in the microcirculation. Results suggest this novel hemodynamic metric should be further evaluated for diagnosing microvascular dysfunction and monitoring peripheral perfusion.
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Affiliation(s)
- Asher A Mendelson
- Department of Medical Biophysics, Western University, London, ON, Canada
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | - Ajay Rajaram
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Keith St Lawrence
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Tracey Bentall
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Michael Sharpe
- Department of Anesthesia and Peri-operative Medicine, Western University, London, ON, Canada
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Mamadou Diop
- Department of Medical Biophysics, Western University, London, ON, Canada
- Imaging Program, Lawson Health Research Institute, London, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Western University, London, ON, Canada.
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada.
- Robarts Research Institute, Rm 3205, London, ON, N6A 5B7, Canada.
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Commentary: Don't sweat the small stuff. J Thorac Cardiovasc Surg 2021; 164:708-709. [PMID: 34876282 DOI: 10.1016/j.jtcvs.2021.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 11/16/2021] [Accepted: 11/17/2021] [Indexed: 11/23/2022]
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Mangukia C, Rali P, Desai P, Ku TSJ, Brann S, Patel S, Sunagawa G, Minakata K, Kehara H, Toyoda Y. Pulmonary endarterectomy. Indian J Thorac Cardiovasc Surg 2021; 37:662-672. [PMID: 34776663 PMCID: PMC8545999 DOI: 10.1007/s12055-021-01208-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 04/24/2021] [Accepted: 04/26/2021] [Indexed: 11/25/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension is an underdiagnosed condition. Patients typically present with the symptoms of right heart failure. Diagnosis is usually done by radionuclide ventilation/perfusion (VQ) scan, high-quality multidetector computed tomography (CT) or pulmonary angiography at expert centers. Pulmonary endarterectomy remains the corner stone in management of chronic thromboembolic pulmonary hypertension. Deep hypothermic circulatory arrest is commonly used for the operation at most centers. In-hospital mortality ranges from 1.7 to 14.2%. Pulmonary hemorrhage, reperfusion lung injury, and right ventricular failure remain major early post-operative concerns. Five-year survival is reported to be 76 to 89%. Long-term outcome depends on residual pulmonary hypertension. Balloon pulmonary angioplasty and medical management play an adjunctive role. Here, we provide a comprehensive review on surgical management of chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Chirantan Mangukia
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Parag Desai
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Tse-Shuen Jade Ku
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Stacey Brann
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Shrey Patel
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Gengo Sunagawa
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Kenji Minakata
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Hiromu Kehara
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
| | - Yoshiya Toyoda
- Division of Cardiovascular Surgery, Temple University Hospital, 3401 N. Broad Street, 3rd Floor, Parkinson Pavilion, Philadelphia, PA 19140 USA
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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45
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Kearney K, Gold J, Corrigan C, Dhital K, Boshell D, Haydock D, McGiffin D, Wilson M, Collins N, Cordina R, Dwyer N, Feenstra J, Lavender M, Wrobel J, Whitford H, Williams T, Keating D, Whyte K, McWilliams T, Keogh A, Strange G, Kotlyar E, Anderson J, Lau EM. Chronic thromboembolic pulmonary hypertension in Australia and New Zealand: An analysis of the PHSANZ registry. Respirology 2021; 26:1171-1180. [PMID: 34608706 DOI: 10.1111/resp.14162] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 07/29/2021] [Accepted: 09/06/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition occurring in 2%-4% of patients after acute pulmonary embolism. Pulmonary endarterectomy (PEA) is a potential cure for technically operable disease. The epidemiology and long-term outcomes of CTEPH have not been previously described in Australia and New Zealand. METHODS Data were extracted from the Pulmonary Hypertension Society of Australia and New Zealand (PHSANZ) registry for patients diagnosed with CTEPH between January 2004 and March 2020. Baseline characteristics, treatment strategies, outcome data and long-term survival are reported. RESULTS A total of 386 patients were included with 146 (37.8%) undergoing PEA and 240 (62.2%) in the non-PEA group. PEA patients were younger (55 ± 16 vs. 62 ± 16 years, p < 0.001) with higher baseline 6-min walk distance (6MWD; 405 ± 122 vs. 323 ± 146 m, p = 0.021), whilst both groups had similar baseline pulmonary haemodynamics. Pulmonary hypertension-specific therapy was used in 54% of patients post-PEA and 88% in the non-PEA group. The 1-, 3- and 5-year survival rates were 93%, 87% and 84% for the PEA group compared to 86%, 73% and 62%, respectively, for the non-PEA group (p < 0.001). Multivariate survival analysis showed baseline 6MWD was an independent predictor of survival in both operated and medically managed patients. CONCLUSION In this first multicentre report of CTEPH in Australia and New Zealand, long-term survival is comparable to that in other contemporary CTEPH registries. However, PEA was only performed in a minority of CTEPH patients (37.8%) and significantly less than overseas reports. Greater awareness of PEA and improved patient access to experienced CTEPH centres are important priorities.
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Affiliation(s)
- Katherine Kearney
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua Gold
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Carolyn Corrigan
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - Kumud Dhital
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Boshell
- Medical Imaging Department, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia
| | - David Haydock
- Greenlane Cardiothoracic Surgical Unit, Auckland City Hospital, Auckland, New Zealand
| | - David McGiffin
- Cardiothoracic Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Wilson
- Macquarie University Hospital, Sydney, New South Wales, Australia
| | | | - Rachael Cordina
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia
| | - Nathan Dwyer
- Cardiology Department, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - John Feenstra
- Thoracic Medicine, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Melanie Lavender
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeremy Wrobel
- Advanced Lung Disease Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Helen Whitford
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Trevor Williams
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Dominic Keating
- Respiratory Medicine, Alfred Hospital, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Ken Whyte
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Tanya McWilliams
- Respiratory Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Anne Keogh
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Geoff Strange
- School of Medicine, University of Notre Dame, Fremantle, Western Australia, Australia
| | - Eugene Kotlyar
- Heart and Lung Transplant Unit, St Vincent's Hospital Sydney, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - James Anderson
- Respiratory Department, Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Edmund Mt Lau
- Sydney Medical School, University of Sydney, Camperdown, New South Wales, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center. J Clin Med 2021; 10:jcm10184251. [PMID: 34575363 PMCID: PMC8466098 DOI: 10.3390/jcm10184251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/15/2021] [Accepted: 09/17/2021] [Indexed: 11/17/2022] Open
Abstract
(1) Background: Clinical presentation, disease distribution, or treatment received may provide insights into the reasons contributing to sex differences in chronic thromboembolic pulmonary hypertension (CTEPH). (2) Methods: We evaluated 453 patients (56% women) between 2007-2019. Data was collected from REHAP (Registro Español de Hipertensión Arterial Pulmonar) registry. Two time periods were selected to evaluate the influence of new treatments over time. (3) Results: Women were older. Baseline functional class was worse, and distance walked shorter in women compared with men. Women had higher pulmonary vascular resistances. Despite this, pulmonary endarterectomy (PEA) was carried out in more men, and women received more frequently pulmonary vasodilators exclusively. The 2014-2019 interval was associated with a better survival only among women. Interestingly, women had a more distal disease during this second period of time. (4) Conclusions: Even though women were older, and received invasive treatments less frequently, mortality was similar in both sexes. The introduction of balloon pulmonary angioplasty and the improvement of pulmonary endarterectomy, especially during the last years, could be associated with a survival benefit among women.
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Scudeller PG, Terra-Filho M, Freitas Filho O, Galas FRBG, Andrade TDD, Nicotari DO, Gobbo LM, Gaiotto FA, Hajjar LA, Jatene FB. Chronic thromboembolic pulmonary hypertension: the impact of advances in perioperative techniques in patient outcomes. J Bras Pneumol 2021; 47:e20200435. [PMID: 34495254 PMCID: PMC8642817 DOI: 10.36416/1806-3756/e20200435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/27/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives Pulmonary endarterectomy (PEA) is the gold standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed at reporting outcomes of CTEPH patients undergoing PEA within 10 years, focusing on advances in anesthetic and surgical techniques. Methods We evaluated 102 patients who underwent PEA between January 2007 and May 2016 at the Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo. Changes in techniques included longer cardiopulmonary bypass, heating, and cooling times and mean time of deep hypothermic circulatory arrest and shortened reperfusion time. Patients were stratified according to temporal changes in anesthetic and surgical techniques: group 1 (January 2007–December 2012), group 2 (January 2013–March 2015), and group 3 (April 2015–May 2016). Clinical outcomes were any occurrence of complications during hospitalization. Results Groups 1, 2, and 3 included 38, 35, and 29 patients, respectively. Overall, 62.8% were women (mean age, 49.1 years), and 65.7% were in New York Heart Association functional class III–IV. Postoperative complications were less frequent in group 3 than in groups 1 and 2: surgical complications (10.3% vs. 34.2% vs. 31.4%, p=0.035), bleeding (10.3% vs. 31.5% vs. 25.7%, p=0.047), and stroke (0 vs. 13.2% vs. 0, p=0.01). Between 3 and 6 months post-discharge, 85% were in NYHA class I–II. Conclusion Improvements in anesthetic and surgical procedures were associated with better outcomes in CTEPH patients undergoing PEA during the 10-year period.
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Affiliation(s)
- Paula Gobi Scudeller
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Mario Terra-Filho
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Orival Freitas Filho
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | | | - Tiago Dutra de Andrade
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Daniela Odnicki Nicotari
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Laura Michelin Gobbo
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Fabio Antonio Gaiotto
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Ludhmila Abrahão Hajjar
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
| | - Fabio Biscegli Jatene
- Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil
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Shetty V, Punnen J, Natarajan P, Orathi S, Khan B, Shetty D. Experience with pulmonary endarterectomy: Lessons learned across 17 years. Asian Cardiovasc Thorac Ann 2021; 30:532-539. [PMID: 34494902 DOI: 10.1177/02184923211044035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pulmonary endarterectomy is potential curative therapy for chronic thromboembolic pulmonary hypertension patients. Here, we present our experience with pulmonary endarterectomy spanning 17 years and detail our management strategy. METHODS This is a single-centre retrospective study conducted on chronic thromboembolic pulmonary hypertension patients who underwent pulmonary endarterectomy at our centre across 17 years. RESULTS Between 2004 and 2020, 591 patients underwent pulmonary endarterectomy. Amongst them 429 (72.4%) were males with a male to female ratio of 2.6:1, the median age was 38 (range, 14-73) years. The median length of hospital stay was 11 days (IQR, 8-16). Extra corporeal membranous oxygenation was used in 82 (13.9%) patients during/after surgery, out of whom 28 (34.1%) survived. There were 70 (11.8%) in-hospital deaths. Female gender (p < 0.01), pulmonary artery systolic pressure >100 mmHg (p < 0.05) and use of extra corporeal membrane oxygenation (p < 0.001) were significant risk factors for in-hospital mortality. The mortality in the first period (2004-2012) was 15.7% which reduced to 9.1% in the later period (2013-2020). The reduction in mortality rate was 42% (p < 0.05). Following pulmonary endarterectomy, there was a significant reduction in pulmonary artery systolic pressure (86.68 ± 24.38 vs. 39.71 ± 13.13 mmHg; p < 0.001) and improvement in median walk distance as measured by 6-min walk test on follow-up (300 vs. 450 meters; p < 0.001). The median duration of follow-up was 8 months (inter-quartile range: 2-24). CONCLUSIONS pulmonary endarterectomy has a learning curve, high pulmonary vascular resistance alone is not a contraindication for surgery. Patients following surgery have improved survival and quality of life.
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Affiliation(s)
- Varun Shetty
- 381800Department of Cardiac Surgery, 501944Narayana Institute of Cardiac Sciences, India
| | - Julius Punnen
- 381800Department of Cardiac Surgery, 501944Narayana Institute of Cardiac Sciences, India
| | - Pooja Natarajan
- Department of Cardiac Anesthesia and Intensive Care, 501944Narayana Institute of Cardiac Sciences, India
| | - Sanjay Orathi
- Department of Cardiac Anesthesia and Intensive Care, 501944Narayana Institute of Cardiac Sciences, India
| | - Basha Khan
- Department of Pulmonology, 501944Narayana Institute of Cardiac Sciences, India
| | - Deviprasad Shetty
- 381800Department of Cardiac Surgery, 501944Narayana Institute of Cardiac Sciences, India
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Yanartaş M, Karakoç AZ, Zengin A, Taş S, Olgun Yildizeli Ş, Mutlu BL, Ataş H, Alibaz-Öner F, Inanç N, Direskeneli H, Bozkurtlar E, Erkilinç A, Çimşit Ç, Bekiroğlu GN, Yildizeli B. Multimodal Approach of Isolated Pulmonary Vasculitis: A Single-Institution Experience. Ann Thorac Surg 2021; 114:1253-1261. [PMID: 34506746 DOI: 10.1016/j.athoracsur.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 07/11/2021] [Accepted: 08/02/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Isolated pulmonary vasculitis (IPV) is a single-organ vasculitis of unknown etiology and may mimic chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to review our clinical experience with pulmonary endarterectomy in patients with CTEPH secondary to IPV. METHODS Data were collected prospectively for consecutive patients who underwent pulmonary endarterectomy and had a diagnosis of IPV at or after surgery. RESULTS We identified nine patients (six female, median age 48 (23-55) years) with IPV. The diagnosis was confirmed after histopathological examination of all surgical materials. The mean duration of disease before surgery was 88.0 ±70.2 months. Exercise-induced dyspnea was the presenting symptom in all patients. Pulmonary endarterectomy was bilateral in six patients and unilateral in three. No mortality was observed, however, one patient had pulmonary artery stenosis and stent implantation was performed. All patients received immunosuppressive therapies after surgery. Mean pulmonary artery pressure decreased significantly from 30(19-67) mm Hg to 21(15-49) mm Hg after surgery (p <0.05). Pulmonary vascular resistance also improved significantly from 270 (160-1600) to 153 (94-548) dyn/s/cm-5 (p<0.05). After a median follow-up of 41 months, all but one patient had improved to the New York Heart Association functional class I. CONCLUSIONS Isolated pulmonary vasculitis can mimic CTEPH, and these patients can be diagnosed with pulmonary endarterectomy. Furthermore, surgery has not only diagnostic but also therapeutic value for IPV when stenotic and/or thrombotic lesions are surgically accessible. A multidisciplinary experienced CTEPH team is critical for management of these unique patients.
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Affiliation(s)
- Mehmed Yanartaş
- University of Health Sciences,Kartal Koşuyolu Teaching and Education Hospital,Department of Cardiovascular Surgery, Istanbul.
| | - Ayşe Zehra Karakoç
- University of Health Sciences,Kartal Koşuyolu Teaching and Education Hospital,Department of Cardiovascular Surgery, Istanbul
| | - Ahmet Zengin
- University of Health Sciences,Kartal Koşuyolu Teaching and Education Hospital,Department of Cardiovascular Surgery, Istanbul
| | - Serpil Taş
- University of Health Sciences,Kartal Koşuyolu Teaching and Education Hospital,Department of Cardiovascular Surgery, Istanbul
| | - Şehnaz Olgun Yildizeli
- Marmara University School of Medicine,Department of Department of Pulmonology and Intensive Care, Istanbul
| | - Bu Lent Mutlu
- Marmara University School of Medicine,Department of Cardiology, Istanbul
| | - Halil Ataş
- Marmara University School of Medicine,Department of Cardiology, Istanbul
| | - Fatma Alibaz-Öner
- Marmara University School of Medicine,Department of Internal Medicine,Division of Rheumatology, Istanbul
| | - Nevsun Inanç
- Marmara University School of Medicine,Department of Internal Medicine,Division of Rheumatology, Istanbul
| | - Haner Direskeneli
- Marmara University School of Medicine,Department of Internal Medicine,Division of Rheumatology, Istanbul
| | - Emine Bozkurtlar
- Marmara University School of Medicine,Department of Pathology, Istanbul
| | - Atakan Erkilinç
- University of Health Sciences,Kartal Koşuyolu Teaching and Education Hospital,Department of Anesthesia, Istanbul
| | - Çagatay Çimşit
- Marmara University School of Medicine,Department of Radiology, Istanbul
| | - G Nural Bekiroğlu
- Marmara University School of Medicine, Department of Biostatistics, Istanbul, Turkey
| | - Bedrettin Yildizeli
- Marmara University School of Medicine,Department of Thoracic Surgery, Istanbul
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50
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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