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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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Ribas Sola J, Sánchez-Corral Mena MÁ, Riera-Mestre A. [Update in the management of chronic thrombo-embolic pulmonary hypertension]. Med Clin (Barc) 2024; 162:126-133. [PMID: 37925273 DOI: 10.1016/j.medcli.2023.08.006] [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: 07/12/2023] [Revised: 08/18/2023] [Accepted: 08/19/2023] [Indexed: 11/06/2023]
Abstract
Chronic thrombo-embolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension (PH) that develops in up to 3% of patients after pulmonary embolism (PE). In these patients, PE does not resolve, leading to organized fibrotic clots, with the development of precapillary PH as a result of the proximal obstruction of the pulmonary arteries. In addition, a distal microvasculopathy may also develop, contributing to the increase of pulmonary vascular resistance. Transthoracic echocardiography is the diagnostic tool that allows to establish the suspicion of PH. Ventilation-perfusion lung scintigraphy is the fundamental tool in the study of patients with suspected CTEPH; if it is normal, virtually rules out the diagnosis. Right heart catheterization is mandatory for the diagnosis of these patients. CTEPH is defined as the existence of symptoms, residual perfusion defects and precapillary PH after a minimum period of three months of anticoagulation. Pulmonary angiography helps determine the extent and surgical accessibility of thromboembolic lesions. CTEPH patients are candidates for long-term anticoagulation. Pulmonary endarterectomy is the treatment of choice, resulting in significant clinical and hemodynamic improvement. About 25% of patients have residual PH post-endarterectomy. Balloon pulmonary angioplasty is an endovascular technique that targets more distal lesions, being potentially useful for patients with inoperable CTEPH or persistent/recurrent PH post-endarterectomy. Both types of patients may also benefit from pharmacological treatment for PH. These three therapies are the cornerstone of CTEPH treatment, which has evolved towards a multimodal approach.
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Affiliation(s)
- Jesús Ribas Sola
- Unidad de Enfermedades Vasculares Pulmonares, Servicio de Neumología, Hospital Universitari de Bellvitge, Barcelona, España; Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España.
| | - Miguel Ángel Sánchez-Corral Mena
- Instituto de Investigación Biomédica de Bellvitge (IDIBELL), Barcelona, España; Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España
| | - Antoni Riera-Mestre
- Unidad de Imagen Cardiaca Avanzada, Servicio de Cardiología, Hospital Universitari de Bellvitge, Barcelona, España; Unidad Funcional de ETV, Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, España; Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, España.
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Pathophysiology and Treatment of Chronic Thromboembolic Pulmonary Hypertension. Int J Mol Sci 2023; 24:ijms24043979. [PMID: 36835383 PMCID: PMC9968103 DOI: 10.3390/ijms24043979] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/10/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a condition in which an organic thrombus remains in the pulmonary artery (PA) even after receiving anticoagulation therapy for more than 3 months and is complicated by pulmonary hypertension (PH), leading to right-sided heart failure and death. CTEPH is a progressive pulmonary vascular disease with a poor prognosis if left untreated. The standard treatment for CTEPH is pulmonary endarterectomy (PEA), which is usually performed only in specialized centers. In recent years, balloon pulmonary angioplasty (BPA) and drug therapy for CTEPH have also shown good results. This review discusses the complex pathogenesis of CTEPH and presents the standard of care, PEA, as well as a new device called BPA, which is showing remarkable progress in efficacy and safety. Additionally, several drugs are now demonstrating established evidence of efficacy in treating CTEPH.
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Faccioli E, Verzeletti V, Perazzolo Marra M, Boscolo A, Schiavon M, Navalesi P, Rea F, Dell’Amore A. Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review of the Most Updated Literature. J Clin Med 2022; 11:jcm11236976. [PMID: 36498551 PMCID: PMC9738233 DOI: 10.3390/jcm11236976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/23/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice in case of chronic thromboembolic pulmonary hypertension (CTEPH). PEA is performed by an increasing number of surgeons; however, the reported outcomes are limited to a few registries or to individual centers' experiences. This systematic review focuses on pre-operative evaluation, intra-operative procedure and post-operative results in patients submitted to PEA for CTEPH. The literature included was searched using a formal strategy, combining the terms "pulmonary endarterectomy" AND "chronic pulmonary hypertension" and focusing on studies published in the last 5 years (2017-2022) to give a comprehensive overview on the most updated literature. The selection of the adequate surgical candidate is a crucial point, and the decision should always be performed by expert multidisciplinary teams composed of surgeons, pulmonologists and radiologists. In all the included studies, the surgical procedure was performed through a median sternotomy with intermittent deep hypothermic circulatory arrest under cardiopulmonary bypass. In case of residual pulmonary hypertension, alternative combined treatments should be considered (balloon angioplasty and/or medical therapy until lung transplantation in highly selected cases). Short- and long-term outcomes, although not homogenous across the different studies, are acceptable in highly experienced CTEPH centers.
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Affiliation(s)
- Eleonora Faccioli
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | | | | | - Annalisa Boscolo
- Intensive Care Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Marco Schiavon
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Paolo Navalesi
- Intensive Care Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Federico Rea
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
| | - Andrea Dell’Amore
- Thoracic Surgery Unit, University Hospital of Padua, 35128 Padua, Italy
- Correspondence:
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