1
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Grafham GK, Bambrick M, Houbois C, Mafeld S, Donahoe L, de Perrot M, McInnis MC. Enhancing preoperative assessment in chronic thromboembolic pulmonary hypertension: A comprehensive analysis of interobserver agreement and proximity-based CT pulmonary angiography scoring. Heliyon 2023; 9:e20899. [PMID: 37954325 PMCID: PMC10632681 DOI: 10.1016/j.heliyon.2023.e20899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Background Surgical risk in chronic thromboembolic pulmonary hypertension (CTEPH) depends on the proximity of thromboembolism on CT pulmonary angiography (CTPA). We assessed interobserver agreement for the quantification of thromboembolic lesions in CTEPH using a novel CTPA scoring index. Methods Forty CTEPH patients (mean age, 58 ± 16 years; 19 men) with preoperative CTPA who underwent pulmonary endarterectomy (PEA) (08/2020-09/2021) were retrospectively included. Three radiologists scored each CTPA for chronic thromboembolism (occlusions, eccentric thickening, webs) using a 32-vessel model of the pulmonary vasculature, with interobserver agreement evaluated using Fleiss' kappa. CT level of disease was determined by the most proximal chronic thromboembolism: level 1 (main pulmonary artery), 2 (lobar), 3 (segmental) and 4 (subsegmental), and compared to surgical level at PEA. Results Interobserver agreement for CT level of disease was moderate overall (κ = 0.52). Agreement was substantial overall at the main/lobar level (κ, mean = 0.71) when excluding the left upper lobe (κ = 0.17). Though segmental and subsegmental agreement suffered (κ = 0.31), we found substantial agreement for occlusions (κ = 0.72) compared to eccentric thickening (κ = 0.45) and webs (κ = 0.14). Correlation between CT level and surgical level was strong overall (τb = 0.73) and in the right lung (τb = 0.68), but weak in the left lung (τb = 0.42) (p < 0.05). Radiologists often over- and underestimated the proximal extent of disease in right and left lung, respectively. Conclusions CT level of disease demonstrated good agreement between radiologists and was highly predictive of the surgical level in CTEPH. Occlusions were the most reliable sign of chronic thromboembolism and are important in assessing the segmental vasculature.
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Affiliation(s)
- Grace K. Grafham
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marie Bambrick
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christian Houbois
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Donahoe
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marc de Perrot
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Micheal C. McInnis
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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2
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Hahn LD, Papamatheakis DG, Fernandes TM, Poch DS, Yang J, Shen J, Hoh CK, Hsiao A, Kerr KM, Pretorius V, Madani MM, Kim NH, Kligerman SJ. Multidisciplinary Approach to Chronic Thromboembolic Pulmonary Hypertension: Role of Radiologists. Radiographics 2023; 43:e220078. [DOI: 10.1148/rg.220078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Lewis D. Hahn
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Demosthenes G. Papamatheakis
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Timothy M. Fernandes
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - David S. Poch
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jenny Yang
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jody Shen
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Carl K. Hoh
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Albert Hsiao
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Kim M. Kerr
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Victor Pretorius
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Michael M. Madani
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Nick H. Kim
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Seth J. Kligerman
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
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Evaluation of Dyspnea and Exercise Intolerance After Acute Pulmonary Embolism. Chest 2022; 163:933-941. [PMID: 35792185 PMCID: PMC10107059 DOI: 10.1016/j.chest.2022.06.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/13/2022] [Accepted: 06/21/2022] [Indexed: 12/13/2022] Open
Abstract
Long-term dyspnea and exercise intolerance are common clinical problems after acute pulmonary embolism. Unfortunately, no single test can distinguish among the range of potential pathologic outcomes after pulmonary embolism. We illustrate a stepwise approach to post-pulmonary embolism evaluation that uses a hierarchic series of clinically validated diagnostic tests. The algorithm is represented by the acronym SEARCH, which stands for Symptom screening, Exercise testing, Arterial perfusion, Resting echocardiography, Confirmatory chest imaging, and Hemodynamics measured by right heart catheterization. We illustrate the algorithm with a patient whom we saw in our pulmonary embolism follow-up clinic. Patients are asked at least 6 months after pulmonary embolism whether they have returned to their baseline level of respiratory comfort and exercise tolerance. Patients with dyspnea and exercise intolerance undergo noninvasive cardiopulmonary exercise testing to identify elevated ventilatory dead space ratios, decreased stroke volume augmentation with exercise, and other physiologic abnormalities during exertion. Ventilation-perfusion scanning is performed on those patients with exercise-related physiologic findings to confirm the presence of residual pulmonary arterial obstruction or to suggest alternative diagnoses. Resting echocardiography may provide evidence of pulmonary hypertension; confirmatory imaging with pulmonary angiography or CT angiography may disclose findings characteristic of chronic pulmonary artery obstruction. Finally, right heart catheterization is performed to confirm chronic thromboembolic pulmonary hypertension; if resting pulmonary hemodynamics are normal, then invasive cardiopulmonary exercise testing may disclose exercise-induced defects.
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4
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McInnis M. Imaging Advances in Chronic Thromboembolic Pulmonary Hypertension. Semin Roentgenol 2022; 57:324-334. [DOI: 10.1053/j.ro.2022.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/29/2022] [Accepted: 07/02/2022] [Indexed: 11/11/2022]
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5
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Yanagisawa A, Naito A, Jujo-Sanada T, Tanabe N, Ishida K, Matsumiya G, Suda R, Kasai H, Sekine A, Sugiura T, Shigeta A, Sakao S, Tatsumi K, Suzuki T. Vascular involvement in chronic thromboembolic pulmonary hypertension is associated with spirometry obstructive impairment. BMC Pulm Med 2021; 21:407. [PMID: 34886828 PMCID: PMC8656012 DOI: 10.1186/s12890-021-01779-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 12/03/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension caused by persistent thromboembolism of the pulmonary arteries. In clinical practice, CTEPH patients often show obstructive ventilatory impairment, even in the absence of a smoking history. Recent reports imply a tendency for CTEPH patients to have a lower FEV1.0; however, the mechanism underlying obstructive impairment remains unknown. METHODS We retrospectively analyzed CTEPH patients who underwent a pulmonary function test and respiratory impedance test to evaluate their exertional dyspnea during admission for right heart catheterization from January 2000 to December 2019. We excluded patients with a smoking history to rule out the effect of smoking on obstructive impairment. RESULTS A total of 135 CTEPH patients were analyzed. The median FEV1.0/FVC was 76.0%, %FEV 1.0 had a negative correlation with the mean pulmonary artery pressure and pulmonary vascular resistance and the CT Angiogram (CTA) obstruction score. A multivariate regression analysis revealed that the CTA obstruction score was an independent factor of a lower %FEV1.0. In the 54 patients who underwent pulmonary endarterectomy, %FEV1.0 was improved in some cases and was not in some. Mean PAP largely decreased after PEA in the better %FEV1.0 improved cases, suggesting that vascular involvement in CTEPH could be associated with spirometry obstructive impairment. CONCLUSION %FEV1.0 had a significant correlation with the CTA obstruction score. Obstructive impairment might have an etiological relationship with vascular involvement. Further investigations could shed new light on the etiology of CTEPH.
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Affiliation(s)
- Asako Yanagisawa
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan.
| | - Akira Naito
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Takayuki Jujo-Sanada
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan.,Pulmonary Hypertension Center, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, Chiba, 260-8670, Japan
| | - Rika Suda
- Pulmonary Hypertension Center, Chibaken Saiseikai Narashino Hospital, Narashino, 275-8580, Japan
| | - Hajime Kasai
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Ayumi Sekine
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
| | - Takuji Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260-8670, Japan
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6
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Maschke SK, Werncke T, Dewald CLA, Becker LS, Meine TC, Olsson KM, Hoeper MM, Wacker FK, Meyer BC, Hinrichs JB. Depiction of mosaic perfusion in chronic thromboembolic pulmonary hypertension (CTEPH) on C-arm computed tomography compared to computed tomography pulmonary angiogram (CTPA). Sci Rep 2021; 11:20042. [PMID: 34625646 PMCID: PMC8501057 DOI: 10.1038/s41598-021-99658-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/23/2021] [Indexed: 11/16/2022] Open
Abstract
To evaluate mosaic perfusion patterns and vascular lesions in patients with chronic thromboembolic pulmonary hypertension (CTEPH) using C-Arm computed tomography (CACT) compared to computed tomography pulmonary angiography (CTPA). We included 41 patients (18 female; mean age 59.9 ± 18.3 years) with confirmed CTEPH who underwent CACT and CTPA within 21 days (average 5.3 ± 5.2). Two readers (R1; R2) independently evaluated datasets from both imaging techniques for mosaic perfusion patterns and presence of CTEPH-typical vascular lesions. The number of pulmonary arterial segments with typical findings was evaluated and the percentage of affected segments was calculated and categorized: < 25%; 25–49%; 50–75%; < 75% of all pulmonary arterial segments affected by thromboembolic vascular lesions. Inter-observer agreement was calculated for both modalities using the intraclass-correlation-coefficient (ICC). Based on consensus reading the inter-modality agreement (CACTcons vs. CTPAcons) was calculated using the ICC. Inter-observer agreement was excellent for central vascular lesions (ICC > 0.87) and the percentage of affected segments (ICC > 0.76) and good for the perceptibility of mosaic perfusion (ICC > 0.6) and attribution of the pattern of mosaic perfusion (ICC > 0.6) for both readers on CACT and CTPA. Inter-modality agreement was excellent for the perceptibility of mosaic perfusion (ICC = 1), the present perfusion pattern (ICC = 1) and central vascular lesions (ICC = 1). However, inter-modality agreement for the percentage of affected segments was fair (ICC = 0.50), with a greater proportion of identified affected segments on CACTcons. CACT demonstrates a high agreement with CTPA regarding the detection of mosaic perfusion. CACT detects a higher number of peripheral vascular lesions compared to CTPA.
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Affiliation(s)
- Sabine K Maschke
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Thomas Werncke
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Cornelia L A Dewald
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Lena S Becker
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Timo C Meine
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Karen M Olsson
- Clinic for Pneumology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Clinic for Pneumology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Frank K Wacker
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Member of the German Center for Lung Research (DZL), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
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7
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Yang X, Zhang L, Ye JQ, Wu XH, Zeng XX, Chen LW, Li YM. The role of ATG-7 contributes to pulmonary hypertension by impacting vascular remodeling. J Mol Cell Cardiol 2021; 157:1-13. [PMID: 33819456 DOI: 10.1016/j.yjmcc.2021.03.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 12/24/2022]
Abstract
AIM Pulmonary hypertension (PH) is a pathophysiological syndrome with functional abnormalities of the pulmonary artery and heart, eventually becoming life threatening to the patients. Autophagy-related gene 7 (ATG)-7 is involved in many cardiovascular diseases, but little is known about the specific role of ATG-7 in the development of PH. We aimed to examine the expression of ATG-7 in PH patients and PH mice, specifically investigate pulmonary physiological responses in a mouse model with conditional deletion of ATG-7 in smooth muscle cells (SMCs) and further clarify the mechanism of PH caused by ATG-7 deficiency. METHODS AND RESULTS SMC-ATG-7-/- mice underwent echocardiography and subsequent pulmonary arterial pressure (PAP) checks. The PAP was lower in wild-type (WT) mice (22.6 ± 2.0 mmHg) than knockout (KO) mice (34.0 ± 2.5 mmHg; p < 0.001). Pulmonary artery resistance was increased in KO (17.61 ± 2.03 mm2·s-1) versus WT mice (8.91 ± 1.62 mm2·s-1; p < 0.005). Combined with these statistics, SMC-ATG7-/- mice were diagnosed with PH. The increase of ATG-7 expression in vessels from PH patients and PH mice were assessed and the effects of ATG-7 on vascular remodeling were investigated in SMCs using relevant methods. We also identified silencing ATG-7 in SMCs induced the increased level of Ca2+ and abnormal proliferation through PP2A/ 4EBP-1/ elf-4E pathway. CONCLUSIONS ATG-7 affects vascular remodeling and exerts a protective function during the pathogenesis of PH. Our study revealed a novel mechanism ATG-7 deficiency promotes cell proliferation via the interaction between PP2A, 4EBP-1 and elf-4E.
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Affiliation(s)
- Xi Yang
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Li Zhang
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China; The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Jian-Qiang Ye
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Xiao-Hui Wu
- School of Pharmacy, Fujian Medical University, Fuzhou 350122, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Xi-Xi Zeng
- The Key Laboratory of Fujian Province University on Ion Channel and Signal Transduction in Cardiovascular Disease, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China.
| | - Yu-Mei Li
- Department of Cardiac Surgery, Fujian Medical University Union Hospital, Fuzhou, China; Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China; Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China.
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8
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Kligerman S, Hsiao A. Optimizing the diagnosis and assessment of chronic thromboembolic pulmonary hypertension with advancing imaging modalities. Pulm Circ 2021; 11:20458940211007375. [PMID: 34104420 PMCID: PMC8150458 DOI: 10.1177/20458940211007375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/10/2020] [Indexed: 02/05/2023] Open
Abstract
Imaging is key to nearly all aspects of chronic thromboembolic pulmonary hypertension including management for screening, assessing eligibility for pulmonary endarterectomy, and post-operative follow-up. While ventilation/perfusion scintigraphy, the gold standard technique for chronic thromboembolic pulmonary hypertension screening, can have excellent sensitivity, it can be confounded by other etiologies of pulmonary malperfusion, and does not provide structural information to guide operability assessment. Conventional computed tomography pulmonary angiography has high specificity, though findings of chronic thromboembolic pulmonary hypertension can be visually subtle and unrecognized. In addition, computed tomography pulmonary angiography can provide morphologic information to aid in pre-operative workup and assessment of other structural abnormalities. Advances in computed tomography imaging techniques, including dual-energy computed tomography and spectral-detector computed tomography, allow for improved sensitivity and specificity in detecting chronic thromboembolic pulmonary hypertension, comparable to that of ventilation/perfusion scans. Furthermore, these advanced computed tomography techniques, compared with conventional computed tomography, provide additional physiologic data from perfused blood volume maps and improved resolution to better visualize distal chronic thromboembolic pulmonary hypertension, an important consideration for balloon pulmonary angioplasty for inoperable patients. Electrocardiogram-synchronized techniques in electrocardiogram-gated computed tomography can also show further information regarding right ventricular function and structure. While the standard of care in the workup of chronic thromboembolic pulmonary hypertension includes a ventilation/perfusion scan, computed tomography pulmonary angiography, direct catheter angiography, echocardiogram, and coronary angiogram, in the future an electrocardiogram-gated dual-energy computed tomography angiography scan may enable a "one-stop" imaging study to guide diagnosis, operability assessment, and treatment decisions with less radiation exposure and cost than traditional chronic thromboembolic pulmonary hypertension imaging modalities.
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Affiliation(s)
- Seth Kligerman
- Cardiothoracic Imaging, University of California San Diego, La Jolla, CA, USA
| | - Albert Hsiao
- Cardiothoracic Imaging, University of California San Diego, La Jolla, CA, USA
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9
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Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
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Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
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10
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Harder EM, Vanderpool R, Rahaghi FN. Advanced Imaging in Pulmonary Vascular Disease. Clin Chest Med 2021; 42:101-112. [PMID: 33541604 DOI: 10.1016/j.ccm.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Although the diagnosis of pulmonary hypertension requires invasive testing, imaging serves an important role in the screening, classification, and monitoring of patients with pulmonary vascular disease (PVD). The development of advanced imaging techniques has led to improvements in the understanding of disease pathophysiology, noninvasive assessment of hemodynamics, and stratification of patient risk. This article discusses the current role of advanced imaging and the emerging novel techniques for visualizing the lung parenchyma, mediastinum, and heart in PVD.
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Affiliation(s)
- Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA.
| | - Rebecca Vanderpool
- Division of Translational and Regenerative Medicine, Department of Medicine, University of Arizona, 1656 East Mabel Street, Tucson, AZ 85721, USA. https://twitter.com/rrvdpool
| | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
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11
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Hajouli S, Moustafa MA, Memoli JSW. Pulmonary Veno-Occlusive Disease: A Rare Cause of Pulmonary Hypertension. J Investig Med High Impact Case Rep 2020; 7:2324709619840375. [PMID: 31010327 PMCID: PMC6480994 DOI: 10.1177/2324709619840375] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare entity that is usually mistaken with pulmonary arterial hypertension (PAH) but is considered class I′ of PAH. It is important to subclassify PVOD and distinguish it from PAH as treatment with vasodilators in PVOD patients is controversial and may be fatal. In this article, we describe a case of PVOD and how we diagnosed it.
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Affiliation(s)
- Said Hajouli
- 1 MedStar Washington Hospital Center, Washington, DC, USA
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12
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Repaired Congenital Heart Disease in Older Children and Adults: Up-to-Date Practical Assessment and Characteristic Imaging Findings. Radiol Clin North Am 2020; 58:503-516. [PMID: 32276700 DOI: 10.1016/j.rcl.2019.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Because of a recent increase in survival rates and life expectancy of patients with congenital heart disease (CHD), radiologists are facing new challenges when imaging the peculiar anatomy of individuals with repaired CHD. Cardiac computed tomography and magnetic resonance are paramount noninvasive imaging tools that are useful in assessing patients with repaired CHD, and both techniques are increasingly performed in centers where CHD is not the main specialization. This review provides general radiologists with insight into the main issues of imaging patients with repaired CHD, and the most common findings and complications of each individual pathology and its repair.
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13
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a life-shortening condition, which may be idiopathic but is more frequently seen in association with other conditions. Current guidelines recommend cardiac catheterization to confirm the diagnosis of pulmonary hypertension. Evidence suggests an increasing role for noninvasive imaging modalities in the initial diagnostic and prognostic assessment and evaluation of treatment response. RECENT FINDINGS In this review we examine the evidence for current noninvasive imaging methodologies: echocardiography computed tomography and MRI in the diagnostic and prognostic assessment of suspected pulmonary hypertension and explore the potential utility of modeling and machine-learning approaches. SUMMARY Noninvasive imaging allows a comprehensive assessment of patients with suspected pulmonary hypertension. It plays a key part in the initial diagnostic and prognostic assessment and machine-learning approaches show promise in the diagnosis of pulmonary hypertension.
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14
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Mikhael M, Makar C, Wissa A, Le T, Eghbali M, Umar S. Oxidative Stress and Its Implications in the Right Ventricular Remodeling Secondary to Pulmonary Hypertension. Front Physiol 2019; 10:1233. [PMID: 31607955 PMCID: PMC6769067 DOI: 10.3389/fphys.2019.01233] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/09/2019] [Indexed: 02/06/2023] Open
Abstract
Pulmonary hypertension (PH) is a pulmonary vascular disease characterized by increased pulmonary artery pressures. Long standing pulmonary arterial pressure overload leads to right ventricular (RV) hypertrophy, RV failure, and death. RV failure is a major determinant of survival in PH. Oxidative stress has been associated with the development of RV failure secondary to PH. Here we summarize the structural and functional changes in the RV in response to sustained pulmonary arterial pressure overload. Furthermore, we review the pre-clinical and clinical studies highlighting the association of oxidative stress with pulmonary vasculature and RV remodeling in chronic PH. Targeting oxidative stress promises to be an effective therapeutic strategy for the treatment of RV failure.
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Affiliation(s)
- Matthew Mikhael
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Christian Makar
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Amir Wissa
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Trixie Le
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Mansoureh Eghbali
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
| | - Soban Umar
- Division of Molecular Medicine, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, UCLA, Los Angeles, CA, United States
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15
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Akizuki M, Sugimura K, Aoki T, Kakihana T, Tatebe S, Yamamoto S, Sato H, Satoh K, Shimokawa H, Kohzuki M. Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension. Respirology 2019; 25:427-434. [DOI: 10.1111/resp.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 04/25/2019] [Accepted: 05/22/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Mina Akizuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Koichiro Sugimura
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Tatsuo Aoki
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Takaaki Kakihana
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
| | - Shunsuke Tatebe
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Saori Yamamoto
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Haruka Sato
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Kimio Satoh
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Hiroaki Shimokawa
- Department of Cardiovascular MedicineTohoku University Graduate School of Medicine Sendai Japan
| | - Masahiro Kohzuki
- Department of Internal Medicine and Rehabilitation ScienceTohoku University Graduate School of Medicine Sendai Japan
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16
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Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
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Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
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17
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de Perrot M, Donahoe L. Pulmonary Thromboendarterectomy: How I Teach It. Ann Thorac Surg 2018; 106:945-950. [DOI: 10.1016/j.athoracsur.2018.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 08/16/2018] [Indexed: 10/28/2022]
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18
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Grosse A, Grosse C, Lang I. Evaluation of the CT imaging findings in patients newly diagnosed with chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13:e0201468. [PMID: 30059549 PMCID: PMC6066236 DOI: 10.1371/journal.pone.0201468] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 07/16/2018] [Indexed: 01/10/2023] Open
Abstract
PURPOSE The aim of this study was to evaluate the vascular and parenchymal CT imaging findings, including vessel and cardiac chamber diameter measurements, in patients newly diagnosed with chronic thromboembolic pulmonary hypertension (CTEPH). The CT imaging findings were correlated with hemodynamic measurements and patient outcome. METHODS Vascular and parenchymal CT findings were assessed on retrospectively ECG-gated MDCT angiography scans in 76 patients newly diagnosed with CTEPH. The diameters of the right and left ventricle (dRV, dLV), the right and left atrium (dRA, dLA), the ascending aorta (dAA), the right and left pulmonary arteries (drPA, dlPA), and the main pulmonary artery (dPA) were measured on axial CT scans. The CT imaging findings were correlated with demographic and hemodynamic data and adverse patient outcome due to right heart failure (RHF). RESULTS The majority of patients showed chronic PE, mosaic perfusion, disparity in segmental vessel size, parenchymal densities, bronchial dilatation, and bronchial collaterals in CT. Mean pulmonary artery pressure (mPAP) was not significantly different in patients with and those without chronic PE, mosaic perfusion, disparity in segmental vessel size, parenchymal densities, bronchial dilatation, and bronchial collaterals. Mean PAP showed significant correlations with the CT metrics of dRV/dLV ratio, dRA, dRV, dPA and dPA/dAA ratio, but no correlation with the central thrombi score. By backward linear regression, the dPA/dAA ratio independently correlated with mPAP. Patients who died of RHF tended to have a higher frequency of exclusively chronic peripheral PE and greater dRV/dLV ratios on presenting CT scans compared with survivors. CONCLUSION The majority of patients newly diagnosed with CTEPH show vascular signs of chronic PE, mosaic perfusion, parenchymal densities, disparity in segmental vessel size, bronchial dilatation, and bronchial collaterals on presenting CT scans. Particularly CTEPH patients with exclusively chronic peripheral PE and increased dRV/dLV ratios seem to be at risk of adverse outcome due to RHF.
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Affiliation(s)
- Alexandra Grosse
- Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Claudia Grosse
- Department of Radiology, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Irene Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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