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Salazar L, Lorusso R. Protected cardiac surgery: strategic mechanical circulatory support to improve postcardiotomy mortality. Curr Opin Crit Care 2024; 30:385-391. [PMID: 38958182 DOI: 10.1097/mcc.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Abstract
PURPOSE OF REVIEW To examine the evolving landscape of cardiac surgery, focusing on the increasing complexity of patients and the role of mechanical circulatory support (MCS) in managing perioperative low cardiac output syndrome (P-LCOS). RECENT FINDINGS P-LCOS is a significant predictor of mortality in cardiac surgery patients. Preoperative risk factors, such as cardiogenic shock and elevated lactate levels, can help identify those at higher risk. Proactive use of MCS, rather than reactive implementation after P-LCOS develops, may lead to improved outcomes by preventing severe organ hypoperfusion. The emerging concept of "protected cardiac surgery" emphasizes early identification of these high-risk patients and planned MCS utilization. Additionally, specific MCS strategies are being developed and refined for various cardiac conditions, including AMI-CS, valvular surgeries, and pulmonary thromboendarterectomy. SUMMARY This paper explores the shifting demographics and complexities in cardiac surgery patients. It emphasizes the importance of proactive, multidisciplinary approaches to identify high-risk patients and implement early MCS to prevent P-LCOS and improve outcomes. The concept of protected cardiac surgery, involving planned MCS use and shared decision-making, is highlighted. The paper also discusses MCS strategies tailored to specific cardiac procedures and the ethical considerations surrounding MCS implementation.
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Affiliation(s)
- Leonardo Salazar
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardio-Thoracic Surgery Intensive Care Unit, Fundación Cardiovascular de Colombia, Bucaramanga, Colombia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CAIM), Maastricht, The Netherlands
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2
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Raguragavan A, Jayabalan D, Dhakal S, Saxena A. A systematic review of the impact of pulmonary thromboendarterectomy on health-related quality of life. Pulm Circ 2024; 14:e12407. [PMID: 38962182 PMCID: PMC11217019 DOI: 10.1002/pul2.12407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 06/13/2024] [Accepted: 06/14/2024] [Indexed: 07/05/2024] Open
Abstract
Pulmonary thromboendarterectomy (PTE) is the current gold standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH) and is a viable treatment option for chronic thromboembolic pulmonary disease (CTEPD). The progressive nature of both diseases severely impacts health-related quality of life (HRQoL) across a variety of domains. This systematic review was performed to evaluate the impact of PTE on short- and long-term HRQoL. A literature search was conducted on PubMed for studies matching the eligibility criteria between January 2000 and September 2022. OVID (MEDLINE), Google Scholar, EBSCOhost (EMBASE), and bibliographies of included studies were reviewed. Inclusion of studies was based on predetermined eligibility criteria. Quality appraisal and data tabulation were performed using predetermined forms. Results were synthesized by narrative review. The structure of this systematic review follows the PRISMA guidelines. This systematic review was prospectively registered in the PROSPERO register (CRD42022342144). Thirteen studies (2184 patients) were included. Within 3 months post-PTE, HRQoL improved in both CTEPD and CTEPH as measured by disease-specific and generic questionnaires. HRQoL improvements were sustained up to 5 years postoperatively in patients with CTEPH post-PTE. PTE remains the gold standard for treating CTEPH and improving HRQoL. Residual pulmonary hypertension and comorbidities such as COPD and coronary artery disease decrement HRQoL over time. The impact of mPAP and PVR on HRQoL outcomes postoperatively remain ambiguous. Pulmonary thromboendarterectomy remains the gold standard for treating CTEPH and has shown to improve HRQoL outcomes at 3-month sustaining improvements up to 5-year postoperatively. Residual pulmonary hypertension and comorbidities hinder HRQoL outcomes post-PTE.
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Affiliation(s)
| | - Dujinthan Jayabalan
- Medical SchoolUniversity of Western AustraliaNedlandsWestern AustraliaAustralia
- Department of HepatologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Sugam Dhakal
- Medical SchoolUniversity of Western AustraliaNedlandsWestern AustraliaAustralia
| | - Akshat Saxena
- Department of Cardiothoracic SurgeryRoyal Hobart HospitalHobartTasmaniaAustralia
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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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Zhang S, Li Y, Yang Y, Gong S, Yang Z, Hong C, Cui X, Wan J, Ji Y, Chen H, Zhu L, Li C, Cheng Z, Zhang Y, Wang Q, Luo Q, Guo L, Ma G, Han B, Liu Z, Xiong C, Wang L, Ji Q, Li F, Wang S, Zhang Z, Zhang Y, Wang D, Gao Q, Huang Q, Xie W, Zhai Z, Wang C. The management pattern and outcomes of chronic thromboembolic pulmonary hypertension: rationale and design for a Chinese real-world study. BMC Pulm Med 2024; 24:265. [PMID: 38825688 PMCID: PMC11145764 DOI: 10.1186/s12890-024-03042-5] [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: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disorder with substantial morbidity and mortality, also a disease underdiagnosed and undertreated. It is potentially curable by pulmonary endarterectomy (PEA) in patients with surgically accessible thrombi. Balloon pulmonary angioplasty (BPA) and targeted medical therapy are options for patients with distal lesions or persistent/recurrent pulmonary hypertension after PEA. There is an urgent need to increase the awareness of CTEPH. Qualified CTEPH centers are still quite limited. Baseline characteristics, management pattern and clinical outcome of CTEPH in China needs to be reported. METHODS AND DESIGN The CHinese reAl-world study to iNvestigate the manaGEment pattern and outcomes of chronic thromboembolic pulmonary hypertension (CHANGE) study is designed to provide the multimodality treatment pattern and clinical outcomes of CTEPH in China. Consecutive patients who are ≥ 14 year-old and diagnosed with CTEPH are enrolled. The diagnosis of CTEPH is confirmed in right heart catheterization and imaging examinations. The multimodality therapeutic strategy, which consists of PEA, BPA and targeted medical therapy, is made by a multidisciplinary team. The blood sample and tissue from PEA are stored in the central biobank for further research. The patients receive regular follow-up every 3 or 6 months for at least 3 years. The primary outcomes include all-cause mortality and changes in functional and hemodynamic parameters from baseline. The secondary outcomes include the proportion of patients experiencing lung transplantation, the proportion of patients experiencing heart and lung transplantation, and changes in health-related quality of life. Up to 31 December 2023, the study has enrolled 1500 eligible patients from 18 expert centers. CONCLUSIONS As a real-world study, the CHANGE study is expected to increase our understanding of CTEPH, and to fill the gap between guidelines and the clinical practice in the diagnosis, assessment and treatment of patients with CTEPH. REGISTRATION NUMBER IN CLINICALTRIALS.GOV: NCT05311072.
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Affiliation(s)
- Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yishan Li
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Sugang Gong
- Dpartments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Cheng Hong
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, P.R. China
| | - Xiaopei Cui
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, P.R. China
| | - Chenghong Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Zhaozhong Cheng
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, P.R. China
| | - Yunhui Zhang
- Department of Respiratory Medicine, The First People's Hospital of Yunnan Province, Kunming, P.R. China
| | - Qiguang Wang
- Division of Pulmonary Vascular Disease, General Hospital of Northern Theater of Command, Shenyang, P.R. China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lu Guo
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, P.R. China
| | - Guofeng Ma
- Department of Respiratory Diseases, Sir Run Run ShawHospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Baoshi Han
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, P.R. China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lan Wang
- Departments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Qiushang Ji
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Fajiu Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, P.R. China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiang Huang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Chen Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
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Vohra AS, Olonoff DA, Ip A, Kirtane AJ, Steinberg Z, Horn E, Krishnan U, Reisman M, Bergman G, Wong S, Feldman DN, Kim LK, Singh HS. Nationwide trends of balloon pulmonary angioplasty and pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (2012-2019). Pulm Circ 2024; 14:e12374. [PMID: 38736894 PMCID: PMC11082429 DOI: 10.1002/pul2.12374] [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: 05/15/2023] [Revised: 03/03/2024] [Accepted: 03/19/2024] [Indexed: 05/14/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes.
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Affiliation(s)
- Adam S. Vohra
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | | | - Ada Ip
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Ajay J. Kirtane
- Department of Medicine, Division of CardiologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Zachary Steinberg
- Department of Medicine, Division of CardiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Evelyn Horn
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Udhay Krishnan
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Mark Reisman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Geoffrey Bergman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Shing‐Chiu Wong
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Dmitriy N. Feldman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Luke K. Kim
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Harsimran S. Singh
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
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Keiler EA, Kerr KM, Poch DS, Yang JZ, Papamatheakis DG, Alotaibi M, Bautista A, Pretorius VG, Madani MM, Kim NH, Fernandes TM. NT-pro-BNP is predictive of morbidity and mortality after pulmonary thromboendarterectomy and is independent of preoperative hemodynamics. Pulm Circ 2024; 14:e12367. [PMID: 38646413 PMCID: PMC11027071 DOI: 10.1002/pul2.12367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 02/12/2024] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Current predictors of clinical outcomes after pulmonary thromboendarterectomy (PTE) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are largely limited to preoperative clinical characteristics. N-terminal-pro-brain natriuretic peptide (NT-pro-BNP), a biomarker of right ventricular dysfunction, has not yet been well described as one such predictor. From 2017 to 2021, 816 patients with CTEPH referred to the University of California, San Diego for PTE were reviewed for differences in NT-pro-BNP to predict preoperative characteristics and postoperative outcomes up to 30 days post-PTE. For analysis, NT-pro-BNP was dichotomized to less than/equal to or greater than 1000 pg/mL based on the mean of the study population. Mean NT-pro-BNP was 1095.9 ±1783.4 pg/mL and median was 402.5 pg/mL (interquartile range: 119.5-1410.8). Of the 816 patients included, 250 had NT-pro-BNP > 1000 pg/mL. Those with NT-pro-BNP > 1000 pg/mL were significantly more likely to have worse preoperative functional class (III-IV) and worse preoperative hemodynamics. Patients with NT-pro-BNP > 1000 pg/mL also tended to have more postoperative complications including reperfusion pulmonary edema (22% vs. 5.1%, p < 0.001), airway hemorrhage (8.4% vs. 4.9%, p = 0.075), residual pulmonary hypertension (11.9% vs. 3.1%, p < 0.001), and 30-day mortality (4.8% vs. 1.1%, p = 0.001). Even after adjusting for confounders, patients with NT-pro-BNP > 1000 pg/mL had a 2.48 times higher odds (95% confidence interval: 1.45-4.00) of reaching a combined endpoint that included the above complications. Preoperative NT-pro-BNP > 1000 pg/mL is a strong predictor of more severe preoperative hemodynamics and identifies patients at higher risk for postoperative complications.
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Affiliation(s)
- Emanuel A. Keiler
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Kim M. Kerr
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - David S. Poch
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Jenny Z. Yang
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Demosthenes G. Papamatheakis
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Mona Alotaibi
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Angela Bautista
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Victor G. Pretorius
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Michael M. Madani
- Division of Cardiovascular and Thoracic SurgerySan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Nick H. Kim
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
| | - Timothy M. Fernandes
- Division of Pulmonary, Critical Care and Sleep MedicineSan Diego Health SystemUniversity of CaliforniaLa JollaCaliforniaUSA
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7
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Awad MA, Cires-Drouet R, Ramani G, Leibowitz JL, Shah A, Lau CL, Griffith BP. Pulmonary thromboendarterectomy in hospitalized versus elective patients with chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg 2024; 167:526-534. [PMID: 37611847 DOI: 10.1016/j.jtcvs.2023.08.018] [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: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE We sought to characterize outcomes in patients undergoing pulmonary thromboendarterectomy electively versus after acute presentation. METHODS This is a retrospective analysis of patients who underwent pulmonary thromboendarterectomy from October 2015 to April 2022. Patients were divided into 2 groups depending on elective surgery or surgery during the same hospitalization as their presentation. RESULTS In total, 69 patients were included: 45 in the hospitalized group and 24 in the elective group. Patients in the hospitalized group were less likely to have chronic lung disease, history of pulmonary embolism and hypertension, be on anticoagulation and medication for pulmonary hypertension, and present with >1 month of respiratory symptoms. They were more likely to have worse preoperative right ventricular function. Among other demographics, risk factors for venous thromboembolism were similar between both groups. Thirteen patients in the hospitalized group required preoperative extracorporeal membrane oxygenation. There was no difference in disease classification and operative, cardiopulmonary bypass, and hypothermic circulatory arrest durations between both groups. Postoperative complications were similar between both groups, except for greater frequency of deep vein thrombosis in the hospitalized group (26.7% vs 4.2%, P = .03). In-hospital and intensive care unit length of stay were similar between both groups. Overall, in-hospital mortality was 4.3% and was similar between both groups; P = .28. CONCLUSIONS Our series shows that pulmonary thromboendarterectomy can be safely performed in patients presenting acutely, with comparable postoperative complications and in-hospital mortality to an elective setting. Such patients present with worse right ventricular function, sometimes requiring temporary mechanical support.
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Affiliation(s)
- Morcos A Awad
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Rafael Cires-Drouet
- Department of Medicine, University of Maryland Medical Center, Baltimore, Md
| | - Gautam Ramani
- Department of Medicine, University of Maryland Medical Center, Baltimore, Md
| | - Joshua L Leibowitz
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Aakash Shah
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Christine L Lau
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Bartley P Griffith
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
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8
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Jenkins DP, Martinez G, Salaunkey K, Reddy SA, Pepke-Zaba J. Perioperative Management in Pulmonary Endarterectomy. Semin Respir Crit Care Med 2023; 44:851-865. [PMID: 37487525 DOI: 10.1055/s-0043-1770123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (PH), provided lesions are proximal enough in the pulmonary vasculature to be surgically accessible and the patient is well enough to benefit from the operation in the longer term. It is a major cardiothoracic operation, requiring specialized techniques and instruments developed over several decades to access and dissect out the intra-arterial fibrotic material. While in-hospital operative mortality is low (<5%), particularly in high-volume centers, careful perioperative management in the operating theater and intensive care is mandatory to balance ventricular performance, fluid balance, ventilation, and coagulation to avoid or treat complications. Reperfusion pulmonary edema, airway hemorrhage, and right ventricular failure are the most problematic complications, often requiring the use of extracorporeal membrane oxygenation to bridge to recovery. Successful PEA has been shown to improve both morbidity and mortality in large registries, with survival >70% at 10 years. For patients not suitable for PEA or with residual PH after PEA, balloon pulmonary angioplasty and/or PH medical therapy may prove beneficial. Here, we describe the indications for PEA, specific surgical and perioperative strategies, postoperative monitoring and management, and approaches for managing residual PH in the long term.
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Affiliation(s)
- David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Guillermo Martinez
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Kiran Salaunkey
- Department of Anaesthesiology, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - S Ashwin Reddy
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS Foundation Trust, Cambridge Biomedical Campus, Cambridge, United Kingdom
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9
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Elhage Hassan M, Vinales J, Perkins S, Sandesara P, Aggarwal V, Jaber WA. Pathogenesis, Diagnosis, and Management of Chronic Thromboembolic Pulmonary Hypertension. Interv Cardiol Clin 2023; 12:e37-e49. [PMID: 38964822 DOI: 10.1016/j.iccl.2024.04.003] [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: 07/06/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to occur as a sequelae of thromboembolic processes in the pulmonary vasculature. The pathophysiology of CTEPH is multifactorial, including impaired fibrinolysis, endothelial dysregulation, and hypoxic adaptations. The diagnosis of CTEPH is typically delayed considering the nonspecific nature of the symptoms, lack of screening, and relatively low incidence. Diagnostic tools include ventilation-perfusion testing, echocardiography, cardiac catheterization, and pulmonary angiography. The only potentially curative treatment for CTEPH is pulmonary endarterectomy However, approximately 40% of patients are inoperable. Currently, only Riociguat is Food and Drug Administration approved specifically for CTEPH, with additional drug trials underway.
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Affiliation(s)
- Malika Elhage Hassan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA
| | - Jorge Vinales
- Department of Medicine, University of Michigan Medical School, 1301 Catherine Street, Ann Arbor, MI 48109, USA
| | - Sidney Perkins
- Department of Internal Medicine, University of Michigan Medical School, 1500 E Medical Center Drive, Ann Arbor, MI 48109, USA
| | - Pratik Sandesara
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA
| | - Vikas Aggarwal
- Department of Cardiology, Henry Ford Medical Center, 2799 W Grand Blvd, K-2 Cath Admin Suite, Detroit, MI 48206, USA
| | - Wissam A Jaber
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, 1364 Clifton Road Northeast Suite F606, Atlanta, GA 30322, USA.
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10
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Ignatov G, Ng CY, Tan Z, Velchev V, Kurkchieva T, Whitbread JC, Valchanov KP. Early experience with pulmonary endarterectomy in Bulgaria-case series. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:216. [PMID: 37007538 PMCID: PMC10061464 DOI: 10.21037/atm-22-4370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 01/08/2023] [Indexed: 03/09/2023]
Abstract
Background Pulmonary arterial hypertension (PAH) is a condition that limits the quality of life and life expectancy. The predicted mortality at 1 year is estimated at 30-40% without treatment. Of the types of PAH, chronic thromboembolic pulmonary hypertension (CTEPH) is most amenable to treatment and guidelines recommend pulmonary endarterectomy (PEA) surgery for 'operable' patients (where disease is found in the proximal pulmonary vessels). Traditionally these patients were referred to a European centre with the complexities of international travel, pre- and post-operative care, and funding. We sought to establish a national PEA programme to serve the Bulgarian population and avoid some of the problems of international healthcare. Case Description A total of 11 patients underwent PEA in 2 cardiac centres in Bulgaria (Acibadem Hospital and Government Hospital Lozenetz Sofia). The age of patients ranged from 22 to 80. The preoperative pulmonary vascular resistance (PVR) ranged from 309 to 1,906 dynes/sec/cm-5. For the surviving patients the average PVR reduction was 615 dynes/sec/cm-5 at 6 months, the average intensive care unit (ICU) stay 6.7 days, and hospitalisation 15.2 days. Nine out of 11 patients survived to hospital discharge and 6 months follow, all with normalised PVR and exercise tolerance. Conclusions We present our results of initial experience with PEA in Bulgaria with encouraging results. Our work shows that inter-European relationship for healthcare can be productive and offer safe treatment on local level.
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Affiliation(s)
- Georgi Ignatov
- Department of Surgery, Lozenetz University Hospital, Sofia, Bulgaria
| | - Choo Yen Ng
- Department of Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Zihui Tan
- Division of Anaesthesiology and Perioperative Medicine, Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
| | - Vasil Velchev
- Department of Cardiology, University Multiprofile Hospital St. Anna, Sofia, Bulgaria
| | - Teodora Kurkchieva
- Department of Perfusion, Acibadem City Clinic, Cardiovascular Centre, Sofia, Bulgaria
| | - Jon C. Whitbread
- Cambridge Perfusion Services, Royal Papworth Hospital, Cambridge, UK
| | - Kamen P. Valchanov
- Division of Anaesthesiology and Perioperative Medicine, Department of Anaesthesiology, Singapore General Hospital, Singapore, Singapore
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Marchetta S, Verbelen T, Claessen G, Quarck R, Delcroix M, Godinas L. A Comprehensive Assessment of Right Ventricular Function in Chronic Thromboembolic Pulmonary Hypertension. J Clin Med 2022; 12:jcm12010047. [PMID: 36614845 PMCID: PMC9821031 DOI: 10.3390/jcm12010047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 12/13/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
While chronic thromboembolic pulmonary hypertension (CTEPH) results from macroscopic and microscopic obstruction of the pulmonary vascular bed, the function of the right ventricle (RV) and increased RV afterload are the main determinants of its symptoms and prognosis. In this review, we assess RV function in patients diagnosed with CTEPH with a focus on the contributions of RV afterload and dysfunction to the pathogenesis of this disease. We will also discuss changes in RV function and geometry in response to treatment, including medical therapy, pulmonary endarterectomy, and balloon pulmonary angioplasty.
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Affiliation(s)
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Rozenn Quarck
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
| | - Marion Delcroix
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Laurent Godinas
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chonic Diseases and Metabolism (CHROMETA), KU Leuven, 3000 Leuven, Belgium
- Department of Pneumology, University Hospitals Leuven, 3000 Leuven, Belgium
- Correspondence:
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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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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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