1
|
Mounsey LA, Witkin AS, Wong A, Kowal A, Hoenstine C, McGinnis S, Malhotra R, Lewis GD, Hardin CC, Rodriguez-Lopez J. Cardiopulmonary Exercise Testing in Patients with Persistent Dyspnea after Pulmonary Embolism. Ann Am Thorac Soc 2023; 20:1528-1530. [PMID: 37311210 DOI: 10.1513/annalsats.202302-108rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/12/2023] [Indexed: 06/15/2023] Open
Affiliation(s)
| | | | | | - Alyssa Kowal
- Massachusetts General Hospital Boston, Massachusetts
| | | | | | | | | | | | | |
Collapse
|
2
|
Zhang E, Virk ZM, Rodriguez-Lopez J, Al-Samkari H. Anticoagulation and antiplatelet therapy in hereditary hemorrhagic telangiectasia: A scoping review. Thromb Res 2023; 226:150-155. [PMID: 37163869 DOI: 10.1016/j.thromres.2023.04.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/02/2023] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
INTRODUCTION Data describing safety and tolerability of anticoagulation and antiplatelet therapy in hereditary hemorrhagic telangiectasia (HHT), the second-most-common inherited bleeding disorder, is limited. METHODS We performed a scoping review, searching MEDLINE and EMBASE from inception to March 2023 for eligible studies reporting detailed clinical data describing antithrombotic use in HHT. Data extracted included study design, patient population, and characteristics and outcomes of antithrombotic therapy. RESULTS Of 625 unique manuscripts identified through database search, 77 were included: 64 case reports/case series describing 65 patients and 13 cohort studies. Data were extracted on a total of 466 patients with HHT, covering 587 episodes of antithrombotic therapy. The most common reasons for antithrombotic therapy were venous thromboembolism (VTE) (44.6 %), atrial arrhythmias (17.8 %) and stroke (10.5 %). anticoagulation was used in in 356 episodes (61.9 %), antiplatelet therapy in 140 episodes (24.3 %), and both together in 50 episodes (8.7 %). Complications of therapy included worsened HHT-associated bleeding (primarily epistaxis and gastrointestinal bleeding) in 198 antithrombotic treatment episodes (38.9 %) and premature antithrombotic therapy discontinuation in 142 episodes (28.9 %). Bleeding-directed therapy (local ablative therapy and systemic therapies) were employed to address worsening bleeding in 14.6 % of episodes. No specific complications of therapy were reported in 322 total antithrombotic events (58.4 %). Rates of bleeding (8.3 % to 80 %), therapy discontinuation (14.3 % to 57.1 %), and other complications ranged considerably from study to study. CONCLUSION Current publications vary widely on the outcomes and tolerability of antithrombotics in HHT, but confirm the clinical challenge of adequate antithrombotic therapy in this population. More formal studies are needed to better guide optimal antithrombotic use in HHT.
Collapse
Affiliation(s)
- Ellen Zhang
- Harvard Medical School, Boston, MA, United States of America
| | - Zain M Virk
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Josanna Rodriguez-Lopez
- Harvard Medical School, Boston, MA, United States of America; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Hanny Al-Samkari
- Harvard Medical School, Boston, MA, United States of America; Division of Hematology, Massachusetts General Hospital, Boston, MA, United States of America.
| |
Collapse
|
3
|
Virk ZM, Zhang E, Rodriguez-Lopez J, Witkin A, Wong AK, Luther J, Lin AE, Ning M, Grabowski E, Holbrook EH, Al-Samkari H. Safety, tolerability, and effectiveness of anticoagulation and antiplatelet therapy in hereditary hemorrhagic telangiectasia. J Thromb Haemost 2023; 21:26-36. [PMID: 36695393 PMCID: PMC10082473 DOI: 10.1016/j.jtha.2022.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/11/2022] [Accepted: 09/29/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Antithrombotic therapy (anticoagulation and antiplatelet therapy) is frequently needed in patients with hereditary hemorrhagic telangiectasia (HHT); however, data describing and guiding its use are very limited. OBJECTIVES To investigate the safety, tolerability, and effectiveness of antithrombotic therapy in HHT in a cohort large enough to compare agents, evaluate for baseline predictors of premature discontinuation, and evaluate hematologic support requirements and healthcare utilization before and after antithrombitc therapy initiation. METHODS We performed a multicenter observational cohort study characterizing the outcomes of antithrombic therapy in adults with HHT. RESULTS A total of 119 patients with HHT with 187 discrete antithrombotic therapy episodes were included. Of these, 59 patients (50%) dose-reduced and/or prematurely discontinued therapy (including 52 patients [44%] who discontinued) due to worsened bleeding complications. Initiation at reduced dose intensity had a similar premature discontinuation rate (49%) as initiation at standard dose intensity (43%). In a multivariable logistic model, a history of gastrointestinal bleeding was associated with 3.25-fold odds of discontinuation (p = .001). Hemoglobin was significantly lower (10.8 g/dL vs 12.2 g/dL, p < .001), and the need for hematologic support (intravenous iron and/or red blood cell transfusion) was significantly higher (29 patients vs 12 patients, p = .004) in the 3 months after antithrombotic therapy initiation vs the 3 months before; emergency department visits and hospital admissions due to bleeding also increased. The rates of dose-reduction and/or premature discontinuation were similar regardless of the anticoagulant class (warfarin, 46%; heparin-based, 48%; direct oral anticoagulants, 44%) or with multiple simultaneous agents (44%) but were slightly lower with single-agent antiplatelet therapy (37%). Thromboembolism despite receiving antithrombotic therapy was common (18 patients, 15%) with varying outcomes. CONCLUSION Antithrombotic therapy is challenging in HHT, resulting in objectively higher morbidity and health care utilization from worsened bleeding. Discontinuation rates approached 50% regardless of the dose intensity at initiation or type of antithrombotic agent used and were higher in patients with a gastrointestinal bleeding history.
Collapse
Affiliation(s)
- Zain M Virk
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ellen Zhang
- Harvard Medical School, Boston, Massachusetts, USA
| | - Josanna Rodriguez-Lopez
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alison Witkin
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alexandra K Wong
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jay Luther
- Harvard Medical School, Boston, Massachusetts, USA; Division of Gastroenterology and Hepatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Angela E Lin
- Harvard Medical School, Boston, Massachusetts, USA; Medical Genetics, Department of Pediatrics, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - MingMing Ning
- Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric Grabowski
- Harvard Medical School, Boston, Massachusetts, USA; Division of Pediatric Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric H Holbrook
- Harvard Medical School, Boston, Massachusetts, USA; Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Institute, Boston, Massachusetts, USA
| | - Hanny Al-Samkari
- Division of Hematology Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
4
|
Al-Samkari H, Kasthuri RS, Parambil JG, Albitar HA, Almodallal YA, Vázquez C, Serra MM, Dupuis-Girod S, Wilsen CB, McWilliams JP, Fountain EH, Gossage JR, Weiss CR, Latif MA, Issachar A, Mei-Zahav M, Meek ME, Conrad M, Rodriguez-Lopez J, Kuter DJ, Iyer VN. An international, multicenter study of intravenous bevacizumab for bleeding in hereditary hemorrhagic telangiectasia: the InHIBIT-Bleed study. Haematologica 2021; 106:2161-2169. [PMID: 32675221 PMCID: PMC8327711 DOI: 10.3324/haematol.2020.261859] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary hemorrhagic telangiectasia (HHT, Osler-Weber-Rendu disease) is a rare multisystem vascular disorder that causes chronic gastrointestinal bleeding, epistaxis, and severe anemia. Bevacizumab, an anti-vascular endothelial growth factor antibody, may be effective to treat bleeding in HHT. This international, multicenter, retrospective study evaluated the use of systemic bevacizumab to treat HHTassociated bleeding and anemia at 12 HHT treatment centers. Hemoglobin, Epistaxis Severity Score (ESS), red cell units transfused, and intravenous iron infusions before and after treatment were evaluated using paired means testing and mixed-effects linear models. Bevacizumab was given to 238 HHT patients for a median of 12 (range, 1-96) months. Compared with pretreatment, bevacizumab increased mean hemoglobin by 3.2 g/dL (95% confidence interval: 2.9-3.5 g/dL); i.e., from a mean hemoglobin of 8.6 (8.5-8.8) g/dL to 11.8 (11.5-12.1) g/dL; P<0.0001) and decreased the ESS by 3.4 (3.2-3.7) points (mean ESS 6.8 [6.6-7.1] versus 3.4 [3.2-3.7]; P<0.0001) during the first year of treatment. Compared with 6 months before treatment, the number of red blood cell units transfused decreased by 82% (median of 6.0 [interquartile range, 0.0-13.0] units versus 0 [0.0-1.0] units; P<0.0001) and iron infusions decreased by 70% (median of 6.0 [1.0-18.0] infusions versus 1.0 [0.0-4.0] infusions, P<0.0001) during the first 6 months of bevacizumab treatment. Outcomes were similar regardless of the underlying pathogenic mutation. Following initial induction infusions, continuous/scheduled bevacizumab maintenance achieved higher hemoglobin and lower ESS than intermittent/as-needed maintenance but with more drug exposure. Bevacizumab was well tolerated: hypertension, fatigue, and proteinuria were the most common adverse events. Venous thromboembolism occurred in 2% of patients. In conclusion, systemic bevacizumab was safe and effective for managing chronic bleeding and anemia in HHT.
Collapse
Affiliation(s)
- Hanny Al-Samkari
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raj S Kasthuri
- Division of Hematology/Oncology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Hasan A Albitar
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Carolina Vázquez
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Marcelo M Serra
- Department of Internal Medicine, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Sophie Dupuis-Girod
- Centre de Reference pour la maladie de Rendu-Osler, Hospices Civils de Lyon, Lyon, France
| | - Craig B Wilsen
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Justin P McWilliams
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Evan H Fountain
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - James R Gossage
- Division of Pulmonary, Critical Care, and Sleep Medicine, Augusta University, Augusta, GA, USA
| | - Clifford R Weiss
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Muhammad A Latif
- Div. of Interventional Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Assaf Issachar
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel, Tel Aviv University, Israel
| | - Mary E Meek
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Miles Conrad
- Dept. of Radiology, University of California San Francisco Medical Center, San Francisco, CA, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David J Kuter
- Division of Hematology, Massachusetts General Hospital, Boston, MA, USA
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
5
|
Abston E, Hon S, Rodriguez-Lopez J, Moll M, Lanuti M, Farber HW, Wilson KC. Treatment of pulmonary hypertension in patients with Hereditary Hemorrhagic Telangiectasia - A case series and systematic review. Pulm Pharmacol Ther 2021; 68:102033. [PMID: 33895318 DOI: 10.1016/j.pupt.2021.102033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 03/22/2021] [Accepted: 04/12/2021] [Indexed: 11/19/2022]
Abstract
RATIONALE Pulmonary Arterial Hypertension (PAH), a rare complication of HHT is associated with poor outcome. There are no trials to date that have investigated whether pulmonary vasodilator therapy improves hemodynamics or survival in this disease. OBJECTIVE To determine whether pulmonary vasodilator therapy improves survival, exercise capacity, or hemodynamics in HHT patients with pre-capillary PH. METHODS We performed a before-and-after observational study on a multicenter cohort of subjects with HHT-PAH who received intravenous prostanoid therapy. We then conducted a systematic review, searching Medline and EMBASE through December 2019. Studies that enrolled HHT-PAH subjects and reported treatment outcomes were selected. PROSPERO #158179. RESULTS Twenty-one articles were selected. Studies were before-and-after observational studies, case reports, and case series. Among all subjects with HHT-PAH, both mPAP (65 ± 19 pre-treatment vs 51 ± 16 mmHg post-treatment p = 0.04) and PVR (12 ± 6 pre-treatment vs 8 ± 4 WU post-treatment p = 0.01) improved with treatment. The mPAP improved with either oral (57 ± 17 pre-treatment versus 44 ± 13 mmHg post-treatment, p = 0.03) or intravenous (80 ± 15 pre-treatment versus 64 ± 16 mmHg post-treatment, p = 0.017) therapy. PVR also improved with either oral (10 ± 4 pre-treatment versus 6 ± 3 WU post-treatment, p = 0.004) or intravenous (17 ± 5 pre-treatment versus 10 ± 4 WU post-treatment, p = 0.04) therapy. Survival among HHT-PAH patients who received oral or intravenous therapy was not different (p = 0.2). Unadjusted survival among HHT-PAH patients was longer than that of IPAH patients (p = 0.008). There was no difference in side effects among HHT-PAH patient who received oral or intravenous therapy (p = 0.1). CONCLUSION Pulmonary vasodilator therapy is effective in improving hemodynamics of subjects with HHT-PAH and was not associated with increased risk of side effects.
Collapse
Affiliation(s)
- Eric Abston
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Center for Thoracic Cancers, Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.
| | - Stephanie Hon
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA; Division of Pulmonary, Critical Care, And Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matt Moll
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Lanuti
- Center for Thoracic Cancers, Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Harrison W Farber
- Division of Pulmonary, Critical Care, And Sleep Medicine, Department of Medicine, Tufts Medical Center, Boston, MA, USA
| | - Kevin C Wilson
- Division of Allergy, Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
| |
Collapse
|
6
|
Farooqui M, Suriya S, Qeadan F, Vigil C, Wegele A, Ikram A, Quadri SA, Robinson M, Rodriguez-Lopez J, Ortega-Gutierrez S, Zafar A. Cerebrovascular and cardiovascular disease burden in patients with hereditary hemorrhagic telangiectasia. Neurol Sci 2021; 42:5117-5122. [PMID: 33779866 DOI: 10.1007/s10072-021-05135-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/20/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Hereditary hemorrhagic telangiectasia (HHT) is a rare genetic disease with prevalence of approximately 1 in 5000-10,000. We evaluated the prevalence and association of cerebrovascular and cardiovascular comorbidities in HHT patients using national database. METHODS Retrospective observational study was performed using National Inpatient Sampling (NIS) database for the year 2014. HHT patients and comorbidities were identified using ICD-9 codes. Univariate and multivariate analyses were performed using SAS. RESULTS Prevalence of HHT was 0.0119% with predominance in White population. Mean age of HHT patients was 59 years. Increased proportion of HHT patients had hypertension (46.8% vs 42%), anemia (28.9% vs 15.1%), chronic pulmonary disease (24.8% vs 16.4%), congestive heart failure (15.7% vs 7.5%), liver disease (7.9% vs 2.8%), migraine (4.5% vs 1.5%), and cerebrovascular malformations (0.8% vs 0.03%), whereas chronic kidney disease (12.7% vs 12.2%), headaches (1.3% vs 1.1%), seizures (0.7% vs 0.9%), transient ischemic attacks (1.06% vs 1.03%), ischemic (1.2% vs 1.0%), and hemorrhagic (0.5% vs 0.3%) strokes were similar to those without HHT. Multivariable model shows increase in cerebrovascular malformations (OR 11.04, CI 2.49-22.26, p < 0.0001), migraine (OR 3.23, CI 2.30-4.52, p < 0.0001), chronic blood loss anemia (OR 6.83, CI 5.36-8.71, p < 0.0001), congestive heart failure (OR 1.55, CI 1.26-1.91, p < 0.0001), chronic pulmonary disease (OR 1.30, CI 1.09-1.56, p = 0.0038), and hepatic disease (OR 2.63, CI 2.01-3.45, p < 0.0001) in HHT patients as compared to non-HHT patients. CONCLUSION There is a need for a large prospective registry of HHT patients that can corroborate these associations and burden of cerebrovascular and cardiovascular diseases.
Collapse
Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Ashley Wegele
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Asad Ikram
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Syed A Quadri
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Myranda Robinson
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Atif Zafar
- Department of Neurology, University of New Mexico Health Sciences Center, University of New Mexico, MSC-10-5620, 1 University of New Mexico, Albuquerque, NM, 87131, USA.
| |
Collapse
|
7
|
Rodriguez-Lopez J, Wright CD, Stone JR, Farber H. When Imaging in Chronic Thromboembolic Pulmonary Hypertension Is Not Enough. Am J Respir Crit Care Med 2021; 203:e3-e4. [PMID: 33026826 DOI: 10.1164/rccm.202003-0785im] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - James R Stone
- Division of Pathology, Massachusetts General Hospital, Boston, Massachusetts; and
| | - Hap Farber
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| |
Collapse
|
8
|
Faughnan ME, Mager JJ, Hetts SW, Palda VA, Lang-Robertson K, Buscarini E, Deslandres E, Kasthuri RS, Lausman A, Poetker D, Ratjen F, Chesnutt MS, Clancy M, Whitehead KJ, Al-Samkari H, Chakinala M, Conrad M, Cortes D, Crocione C, Darling J, de Gussem E, Derksen C, Dupuis-Girod S, Foy P, Geisthoff U, Gossage JR, Hammill A, Heimdal K, Henderson K, Iyer VN, Kjeldsen AD, Komiyama M, Korenblatt K, McDonald J, McMahon J, McWilliams J, Meek ME, Mei-Zahav M, Olitsky S, Palmer S, Pantalone R, Piccirillo JF, Plahn B, Porteous MEM, Post MC, Radovanovic I, Rochon PJ, Rodriguez-Lopez J, Sabba C, Serra M, Shovlin C, Sprecher D, White AJ, Winship I, Zarrabeitia R. Second International Guidelines for the Diagnosis and Management of Hereditary Hemorrhagic Telangiectasia. Ann Intern Med 2020; 173:989-1001. [PMID: 32894695 DOI: 10.7326/m20-1443] [Citation(s) in RCA: 187] [Impact Index Per Article: 46.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
DESCRIPTION Hereditary hemorrhagic telangiectasia (HHT) is an autosomal dominant disease with an estimated prevalence of 1 in 5000 that is characterized by the presence of vascular malformations (VMs). These result in chronic bleeding, acute hemorrhage, and complications from shunting through VMs. The goal of the Second International HHT Guidelines process was to develop evidence-based consensus guidelines for the management and prevention of HHT-related symptoms and complications. METHODS The guidelines were developed using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) framework and GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. The guidelines expert panel included expert physicians (clinical and genetic) in HHT from 15 countries, guidelines methodologists, health care workers, health care administrators, patient advocacy representatives, and persons with HHT. During the preconference process, the expert panel generated clinically relevant questions in 6 priority topic areas. A systematic literature search was done in June 2019, and articles meeting a priori criteria were included to generate evidence tables, which were used as the basis for recommendation development. The expert panel subsequently convened during a guidelines conference to conduct a structured consensus process, during which recommendations reaching at least 80% consensus were discussed and approved. RECOMMENDATIONS The expert panel generated and approved 6 new recommendations for each of the following 6 priority topic areas: epistaxis, gastrointestinal bleeding, anemia and iron deficiency, liver VMs, pediatric care, and pregnancy and delivery (36 total). The recommendations highlight new evidence in existing topics from the first International HHT Guidelines and provide guidance in 3 new areas: anemia, pediatrics, and pregnancy and delivery. These recommendations should facilitate implementation of key components of HHT care into clinical practice.
Collapse
Affiliation(s)
- Marie E Faughnan
- St. Michael's Hospital, Li Ka Shing Knowledge Institute, and University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | | | - Steven W Hetts
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | | | | | | | - Erik Deslandres
- Centre Hospitalier de l'Université de Montréal, Hôtel-Dieu, Montreal, Quebec, Canada (E.D.)
| | - Raj S Kasthuri
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | - Andrea Lausman
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - David Poetker
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Felix Ratjen
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada (F.R.)
| | - Mark S Chesnutt
- VA Portland Health Care System and Oregon Health & Science University, Portland, Oregon (M.S.C.)
| | | | - Kevin J Whitehead
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | - Hanny Al-Samkari
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (H.A.)
| | - Murali Chakinala
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Miles Conrad
- University of California, San Francisco, San Francisco, California (S.W.H., M.C.)
| | - Daniel Cortes
- St. Michael's Hospital and Unity Health Toronto, Toronto, Canada (D.C.)
| | | | - Jama Darling
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (R.S.K., J.D.)
| | | | | | | | - Patrick Foy
- Froedtert and Medical College of Wisconsin, Milwaukee, Wisconsin (D.P., P.F.)
| | - Urban Geisthoff
- University Hospital of Marburg and Phillips University Marburg, Marburg, Germany (U.G.)
| | | | - Adrienne Hammill
- Cincinnati Children's Hospital and University of Cincinnati, Cincinnati, Ohio (A.H.)
| | - Ketil Heimdal
- Oslo University Hospital, Rikshospitalet, Oslo, Norway (K.H.)
| | | | | | | | | | - Kevin Korenblatt
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Jamie McDonald
- University of Utah Medical Center, Salt Lake City, Utah (K.J.W., J.M.)
| | | | - Justin McWilliams
- University of California, Los Angeles, Los Angeles, California (J.M.)
| | - Mary E Meek
- University of Arkansas for Medical Sciences, Little Rock, Arkansas (M.E.M.)
| | - Meir Mei-Zahav
- Schneider Children's Medical Center of Israel and Sackler School of Medicine of Tel Aviv University, Tel Aviv, Israel (M.M.)
| | | | | | - Rose Pantalone
- St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada (A.L., R.P.)
| | - Jay F Piccirillo
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | | | | | - Marco C Post
- St. Antonius Hospital, Nieuwegein, and University Medical Center Utrecht, Utrecht, the Netherlands (M.C.P.)
| | - Ivan Radovanovic
- Toronto Western Hospital and University of Toronto, Toronto, Ontario, Canada (I.R.)
| | - Paul J Rochon
- University of Colorado Hospital, Aurora, Colorado (P.J.R.)
| | | | | | - Marcelo Serra
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina (M.S.)
| | | | | | - Andrew J White
- Washington University School of Medicine, St. Louis, Missouri (M.C., K.K., J.F.P., A.J.W.)
| | - Ingrid Winship
- Royal Melbourne Hospital and University of Melbourne, Melbourne, Victoria, Australia (I.W.)
| | - Roberto Zarrabeitia
- Hospital Sierrallana (Servicio Cántabro de Salud), Torrelavega, Spain (R.Z.)
| |
Collapse
|
9
|
Johnson SW, Witkin A, Rodriguez-Lopez J, Channick R. Room for improvement in pulmonary capillary wedge pressure reporting: a review of hemodynamic tracings at a large academic medical center. Pulm Circ 2020; 10:2045894020929157. [PMID: 33240481 PMCID: PMC7672742 DOI: 10.1177/2045894020929157] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/01/2020] [Indexed: 01/06/2023] Open
Abstract
To describe the frequency with which pulmonary capillary wedge pressure measurements, obtained during right heart catheterization, are falsely elevated and to educate operators on techniques to improve accuracy of pulmonary capillary wedge pressure reporting. Failure to completely occlude pulmonary artery branch vessels during balloon inflation can lead to falsely elevated, “incomplete” pulmonary capillary wedge pressures. Balloon deflation prior to catheter retraction may result in catheter advancement into smaller branch vessels, yielding an inadvertent but more accurate alternative pulmonary capillary wedge pressure. We hypothesized that this phenomenon can be identified on retrospective review of right heart catheterization tracings, which occurs commonly and goes unrecognized by operators. We conducted a retrospective study of patients undergoing right heart catheterization or right heart catheterization and left heart catheterization with computer-generated pulmonary capillary wedge pressure ≥20 from January 2015 to June 2017. Alternative pulmonary capillary wedge pressures were defined as a pulmonary capillary wedge pressure trace during balloon deflation ≥3 mmHg lower than the reported pulmonary capillary wedge pressure. Inter-rater reliability of tracing reviewers was also evaluated. Results showed that, of the 182 tracings reviewed, an alternative pulmonary capillary wedge pressure was identified in 26 or 14.3% of cases. Eleven of these alternative pulmonary capillary wedge pressures were ≤15 mmHg with a calculated pulmonary vascular resistance ≥3 Wood units in 10 patients, re-classifying the etiology of pulmonary hypertension from post-capillary to pre-capillary in 38.5% of cases. For the eight patients for whom left heart catheterization data were available, left ventricular end-diastolic pressure aligned with the alternative pulmonary capillary wedge pressure. In conclusion, inadvertently obtained, but likely more accurate, alternative pulmonary capillary wedge pressures were identified in almost 15% of procedures reviewed from a busy academic institution. As wedge pressures often drive diagnosis and treatment decisions for patients with cardiac and pulmonary pathology, operators should be attuned to balloon deflation as a time when alternative pulmonary capillary wedge pressures may be identified as they are likely more reflective of left ventricular end-diastolic pressure. Additional tools to ensure accuracy of pulmonary capillary wedge pressure reporting are reviewed.
Collapse
Affiliation(s)
- Shelsey W Johnson
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Alison Witkin
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Josanna Rodriguez-Lopez
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Richard Channick
- Department of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
10
|
Kohli P, Kelly VJ, Kehl EG, Rodriguez-Lopez J, Hibbert KA, Kone M, Systrom DM, Waxman AB, Venegas JG, Channick R, Winkler T, Harris RS. Perfusion Imaging Distinguishes Exercise Pulmonary Arterial Hypertension at Rest. Am J Respir Crit Care Med 2020; 199:1438-1441. [PMID: 30811948 DOI: 10.1164/rccm.201810-1899le] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Puja Kohli
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | | | - Ekaterina G Kehl
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | | | - Kathryn A Hibbert
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Mamary Kone
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - David M Systrom
- 3 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
| | - Aaron B Waxman
- 3 Brigham and Women's Hospital and Harvard Medical School Boston, Massachusetts
| | - Jose G Venegas
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Richard Channick
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - Tilo Winkler
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| | - R Scott Harris
- 1 Massachusetts General Hospital and Harvard Medical School Boston, Massachusetts
| |
Collapse
|
11
|
Chin K, Kim N, McLaughlin V, Frantz R, Rodriguez-Lopez J, Brand M, Flynn M, Leroy S, Morganti A, Channick R. MACITENTAN IN THE ELDERLY POPULATION WITH PULMONARY ARTERIAL HYPERTENSION: REAL-WORLD EVIDENCE FROM THE COMBINED OPUS REGISTRY AND ORPHEUS COHORT. Chest 2019. [DOI: 10.1016/j.chest.2019.08.376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
12
|
Berra L, Rodriguez-Lopez J, Rezoagli E, Yu B, Fisher DF, Semigran MJ, Bloch DB, Channick RN, Zapol WM. Electric Plasma-generated Nitric Oxide: Hemodynamic Effects in Patients with Pulmonary Hypertension. Am J Respir Crit Care Med 2017; 194:1168-1170. [PMID: 27797618 DOI: 10.1164/rccm.201604-0834le] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Lorenzo Berra
- 1 Massachusetts General Hospital Boston, Massachusetts
| | | | | | - Binglan Yu
- 1 Massachusetts General Hospital Boston, Massachusetts
| | | | | | | | | | | |
Collapse
|
13
|
Jain CC, Chang Y, Kabrhel C, Giri J, Channick R, Rodriguez-Lopez J, Rosovsky RP, Fogerty A, Rosenfield K, Jaff MR, Weinberg I. Impact of Pulmonary Arterial Clot Location on Pulmonary Embolism Treatment and Outcomes (90 Days). Am J Cardiol 2017; 119:802-807. [PMID: 28153347 DOI: 10.1016/j.amjcard.2016.11.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Revised: 11/03/2016] [Accepted: 11/03/2016] [Indexed: 10/20/2022]
Abstract
Pulmonary embolism (PE) is common and management is based on risk stratification. The significance of clot location in submassive and massive PE is unclear. Data from a prospectively gathered database of submassive and massive PE were used for analysis. Available data included patient presentation, diagnostics, treatment, and outcome. Comparisons were made according to clot location: central or peripheral. A multivariable model was used for composite outcome of death or right ventricular (RV) strain at 90 days. Among 269 patients, there were no significant demographic differences between patients with peripheral and central PE. Peripheral PE was more likely to present with hypotension (46.4% vs 32.6%; p = 0.02), but central PE was more likely to have RV strain on echocardiography (76.7% vs 57.7%, p <0.001) and computed tomography (58.1% vs 32.0%, p <0.0001). Peripheral PE was more likely to receive anticoagulation as the only form of therapy (69.1% vs 55.8%; p = 0.03), and central PE was more likely to receive catheter-directed therapies (18.3% vs 3.3%; p <0.001). Nonetheless, peripheral PE had higher 30- and 90-day all-cause mortality (18.5% vs 9.3%; p = 0.03; 25.9% vs 13.5%; p = 0.02, respectively). In a multivariable analysis, the only independent predictor of death or RV strain at 90 days was increased age (odds radio 1.35, CI 1.06 to 1.72 per 10 years). Specifically, neither clot location nor treatment was associated with patient outcomes. In conclusion, in this cohort of patients with submassive and massive PE, clot location was associated with treatment patterns but not patient outcomes to 90 days. Reevaluation of practice is thus warranted.
Collapse
|
14
|
Abstract
Treatment of patients with intermediate- and high-risk pulmonary embolism (PE) is a controversial area. Many therapeutic options exist, and deciding on appropriate treatment can be difficult. In addition, multiple specialties are often involved in the care of PE patients. To better organize the response to serious PE patients, several hospitals and academic centers across the United States, spearheaded by Massachusetts General Hospital, have created pulmonary embolism response teams (PERTs). The goal of a PERT is to have a single multidisciplinary team of experts in thromboembolic disease, who can respond rapidly to patients with acute PE, and offer consultation with the full spectrum of therapeutic options. PERT teams were modeled after rapid response teams and are meant to generate a prompt, patient-specific plan for patients with PE without having to consult multiple individual specialists.
Collapse
Affiliation(s)
- Josanna Rodriguez-Lopez
- Pulmonary Hypertension and Thromboendarterectomy Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Richard Channick
- Pulmonary Hypertension and Thromboendarterectomy Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
15
|
Kabrhel C, Rosovsky R, Channick R, Jaff MR, Weinberg I, Sundt T, Dudzinski DM, Rodriguez-Lopez J, Parry BA, Harshbarger S, Chang Y, Rosenfield K. A Multidisciplinary Pulmonary Embolism Response Team. Chest 2016; 150:384-93. [DOI: 10.1016/j.chest.2016.03.011] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 02/05/2016] [Accepted: 03/01/2016] [Indexed: 11/28/2022] Open
|
16
|
Emin M, Wang G, Castagna F, Rodriguez-Lopez J, Wahab R, Wang J, Adams T, Wei Y, Jelic S. Increased internalization of complement inhibitor CD59 may contribute to endothelial inflammation in obstructive sleep apnea. Sci Transl Med 2016; 8:320ra1. [PMID: 26738794 PMCID: PMC5485919 DOI: 10.1126/scitranslmed.aad0634] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Obstructive sleep apnea (OSA), characterized by intermittent hypoxia (IH) during transient cessation of breathing, triples the risk for cardiovascular diseases. We used a phage display peptide library as an unbiased approach to investigate whether IH, which is specific to OSA, activates endothelial cells (ECs) in a distinctive manner. The target of a differentially bound peptide on ECs collected from OSA patients was identified as CD59, a major complement inhibitor that protects ECs from the membrane attack complex (MAC). A decreased proportion of CD59 is located on the EC surface in OSA patients compared with controls, suggesting reduced protection against complement attack. In vitro, IH promoted endothelial inflammation predominantly via augmented internalization of CD59 and consequent MAC deposition. Increased internalization of endothelial CD59 in IH appeared to be cholesterol-dependent and was reversed by statins in a CD59-dependent manner. These studies suggest that reduced complement inhibition may mediate endothelial inflammation and increase vascular risk in OSA patients.
Collapse
Affiliation(s)
- Memet Emin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Gang Wang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Francesco Castagna
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Josanna Rodriguez-Lopez
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Romina Wahab
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Jing Wang
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Tessa Adams
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Ying Wei
- Division of Biostatistics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA
| | - Sanja Jelic
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA,Corresponding author.
| |
Collapse
|
17
|
Gonzalez-Valero L, Rodriguez-Lopez J, Lachica M, Fernandez-Figares I. Differences in portal appearance of lysine and methionine in Iberian and Landrace pigs. J Anim Sci 2013; 90 Suppl 4:110-2. [PMID: 23365299 DOI: 10.2527/jas.51774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Compared to modern breeds, Iberian pigs have lower rates of muscle protein deposition and greater viscera weight. Factors that limit growth performance of Iberian pigs are unknown. We hypothesized that differences in net portal appearance of the essential AA Lys and Met might partially explain the lower growth rate reported in Iberian pigs compared to modern breeds. Net portal appearance of AA was measured in 6 Iberian and 6 Landrace gilts (28 kg BW) fitted with chronic catheters in the portal vein, carotid artery, and mesenteric vein. Blood samples were taken for 6 h after feeding 2 isoenergetic diets (14.0 to 14.5 MJ ME/kg DM) with low CP (LCP) and high CP (HCP) (13 vs. 16%, respectively) in a crossover design after a 1-wk adaptation. Net portal appearance of Lys was greater (P < 0.05) when pigs consumed the HCP than LCP diet (23 vs. 15 μmol/min); breeds did not differ. Net portal appearance of Met tended to be higher (P = 0.076) for pigs fed HCP than LCP diet (4.4 vs. 3.6 μmol/min); breeds did not differ. In conclusion, differences in portal appearance of Lys and Met did not exist between Iberian and Landrace pigs fed barley (Hordeum vulgare)-soybean (Glycine max) diets with low and high protein concentration.
Collapse
Affiliation(s)
- L Gonzalez-Valero
- Institute of Animal Nutrition, Estacion Experimental del Zaidin, CSIC, Profesor Albareda 1, 18008 Granada, Spain
| | | | | | | |
Collapse
|
18
|
M. Pavan G, Monteagudo S, Guerra J, Carrion B, Ocana V, Rodriguez-Lopez J, Danani A, C. Perez-Martinez F, Cena V. Role of Generation, Architecture, pH and Ionic Strength on Successful siRNA Delivery and Transfection by Hybrid PPV-PAMAM Dendrimers. Curr Med Chem 2012; 19:4929-41. [DOI: 10.2174/0929867311209024929] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Revised: 05/28/2012] [Accepted: 08/01/2012] [Indexed: 11/22/2022]
|
19
|
Rodriguez-Lopez J, Pombo-Suarez M, Loughlin J, Tsezou A, Blanco FJ, Meulenbelt I, Slagboom PE, Valdes AM, Spector TD, Gomez-Reino JJ, Gonzalez A. Association of a nsSNP in ADAMTS14 to some osteoarthritis phenotypes. Osteoarthritis Cartilage 2009; 17:321-7. [PMID: 18790654 DOI: 10.1016/j.joca.2008.07.012] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Accepted: 07/29/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the effect in OA (Osteoarthritis) susceptibility of putative damaging changes in ADAM (A Disintegrin And Metalloprotease) and ADAMTS (ADAM with ThromboSpondin motif) proteases. METHODS Non-synonymous single nucleotide polymorphisms (nsSNP) in 18 ADAMTS and 31 ADAM genes were analyzed with two software applications for prediction of functional damage. Four putative damaging nsSNP were found in ADAMTS2, ADAMTS14, ADAMTS16 and ADAM12, respectively. These nsSNPs were analyzed in case-control sample collections with a variety of phenotypes totalling 3217 OA patients and 2214 healthy controls, all of them Caucasians. RESULTS No statistically significant differences were found in ADAMTS2, ADAMTS16 and ADAM12 nsSNPs. Conversely, the rare allele of the rs4747096 nsSNP in ADAMTS14 was overrepresented in women requiring joint replacement because of knee OA (O.R.(M-H) (odds ratio. Mantel-Haenszel)=1.41, 95% C.I.=1.1-1.8; P=0.002) and in patients with symptomatic hand OA (O.R.=1.37, 95% C.I.=1.0-1.9; P=0.047). A non significant increase in the frequency of the same allele was also found in patients with hip OA requiring prosthesis (O.R.(M-H)=1.14, 95% C.I.=1.0-1.3; P=0.08). No association was found with other OA phenotypes. CONCLUSION Our findings implicate ADAMTS14 in OA, specifically in knee OA requiring joint replacement in women and, possibly, in hand OA. Independent association of ADAMTS14 genetic variation to knee OA in women has been communicated. ADAMTS14 involvement, if confirmed, will open a new area of interest in OA pathogenesis because of its role in the maturation of collagen fibers.
Collapse
Affiliation(s)
- J Rodriguez-Lopez
- Laboratorio Investigacion 2 and Rheumatology Unit, Hospital Clinico Universitario Santiago, Santiago de Compostela, Spain
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
20
|
Rodriguez-Lopez J, Pombo-Suarez M, Liz M, Gomez-Reino JJ, Gonzalez A. Further evidence of the role of frizzled-related protein gene polymorphisms in osteoarthritis. Ann Rheum Dis 2007; 66:1052-5. [PMID: 17237116 PMCID: PMC1954696 DOI: 10.1136/ard.2006.065938] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To replicate the association of frizzled-related protein (FRZB) non-synonymous polymorphisms with osteoarthritis (OA) susceptibility. METHODS Three groups of Spanish patients with OA were included: with total joint replacement due to primary OA in the hip (n = 310), or the knee (n = 277), or with hand OA (n = 242). Controls were more than 55 years old and did not show OA (n = 294). SNPs rs288326 (R200W) and rs7775 (R324G) were genotyped. RESULTS There were no significant differences in allele frequencies between controls and each of the three groups of OA patients. However, allele G of the R324G SNP showed a trend to be more frequent in patients with a clinical OA syndrome at multiple joints (p = 0.07), specifically in women of the total hip replacement group (8.3% in patients without other affected joints, 13.1% with one, 15.9% with two and 24.1% with more than two additional joints, p for trend = 0.008). CONCLUSIONS No direct replication of previous OA association findings was obtained but the results suggest that the R324G SNP of the FRZB gene may have an effect in OA development in multiple joints, with a specific severe involvement of the hip in women. This phenotype could reconcile previous studies that showed association either with generalised OA or with hip OA in women.
Collapse
Affiliation(s)
- J Rodriguez-Lopez
- Laboratorio de Investigacion 2, Hospital Clinico Universitario de Santiago, Travesia de Choupana sn, 15706-Santiago de Compostela, Spain
| | | | | | | | | |
Collapse
|
21
|
Lobato AC, Rodriguez-Lopez J, Malik A, Vranic M, Vaughn PL, Douglas M, Diethrich EB. Impact of endovascular repair for abdominal aortic aneurysms in octogenarians. Ann Vasc Surg 2001; 15:525-32. [PMID: 11665435 DOI: 10.1007/s100160010120] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
A total of 50 consecutive patients (86% male; median age, 82 years) underwent endovascular repair of abdominal aortic aneurysms (AAAs) ranging from 4.0 to 9.0 cm (median, 5.2 cm). Efficacy of aneurysm exclusion was assessed by angiography, duplex scan, and/or contrast-enhanced computed tomography (CT). Acute technical success was 82%. Access failed in one patient, and immediate conversion to open operation was required in two patients. Improper deployment of the endoluminal graft (ELG) across the renal arteries occurred in one patient. The median operation time, estimated blood loss, packed red blood cells received, contrast volume, and length of intensive care and hospital stay were 128 min, 200 mL, 0.1 unit, 297 mL, 0.9 days, and 3 days, respectively. ELG limb thrombosis was seen in one patient. There were 4 (8%) early endoleaks, and 2 endoleaks were discovered in other patients at 3 and 6 months. Local/vascular and remote/systemic postoperative complications were seen in 13 (26%) and 9 (18%) patients, respectively. At a median follow-up of 11 months (range 2 to 36 months), clinical success was 78%. The aneurysm sac diameter (n = 49) decreased from a preoperative median of 5.2 to 4.7 cm (p = 0.0001). Technical success was high, and results at 11 months were satisfactory. Long-term outcomes require further study.
Collapse
Affiliation(s)
- A C Lobato
- Department of Cardiovascular Surgery, Arizona Heart Institute and Foundation, Arizona Heart Hospital, 2632 North 20th Street, Phoenix, AZ 85006, USA
| | | | | | | | | | | | | |
Collapse
|
22
|
Lobato AC, Quick RC, Vaughn PL, Rodriguez-Lopez J, Douglas M, Diethrich EB. Transrenal fixation of aortic endografts: intermediate follow-up of a single-center experience. J Endovasc Ther 2000; 7:273-8. [PMID: 10958290 DOI: 10.1177/152660280000700403] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the fate of the renal ostia following transrenal fixation of endovascular aortic stent-grafts. METHODS Thirty-five patients (29 men; mean age 75 years) undergoing endovascular repair for abdominal aortic aneurysms (AAAs) had transrenal fixation of the uncovered proximal stent due to a short (< 1.5 cm long) or conical neck or a periprocedural endoleak. Eighteen (51%) patients were hypertensive; 7 (20%) had renal artery stenoses (RAS). Outcome measures included blood pressure, serum creatinine, computed tomography, and renal artery duplex scans. RESULTS Two patients with > or = 60% RAS had renal stents placed during the endograft procedure; the other 5 RAS patients were normotensive and their renal lesions were not treated. Overall technical success was 82.9% (29/35). One (2.9%) case was converted due to graft twisting. There were 5 (14.2%) early endoleaks. Transient postoperative creatinine elevations were observed in 5 (14.2%) cases. Over a median 11-month period (range 2-24), no secondary endoleaks or silent renal artery occlusions were seen. One normotensive patient with an untreated > or = 60% renal lesion developed hypertension and severe stenosis (99%) at 4 months; stenting through the interstices of the transrenal stent was performed. No disease progression was seen in the other 6 RAS patients. CONCLUSIONS In the intermediate period, transrenal fixation appears to have no adverse effects on renal blood flow. Moreover, in patients with no evidence of renal disease or preoperative RAS < 60%, it does not precipitate or cause progression of renal stenosis. However, patients with preoperatively documented RAS > or = 60% are a concern and mandate further study.
Collapse
Affiliation(s)
- A C Lobato
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, Phoenix 85006, USA
| | | | | | | | | | | |
Collapse
|
23
|
Lobato AC, Quick RC, Phillips B, Vranic M, Rodriguez-Lopez J, Douglas M, Diethrich EB. Immediate endovascular repair for descending thoracic aortic transection secondary to blunt trauma. J Endovasc Ther 2000; 7:16-20. [PMID: 10772744 DOI: 10.1177/152660280000700103] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To report the immediate endovascular treatment of a thoracic aortic tear secondary to blunt trauma. METHODS AND RESULTS A 39-year-old man was injured in a motor vehicle collision. In addition to significant trauma to the head, chest, and abdomen, there were signs of a deceleration injury to the thoracic aorta. After urgent celiotomy to repair a lacerated spleen, the thoracic aortic transection was treated intraluminally using an endograft made of Gianturco Z-stents covered with polytetrafluoroethylene. The patient recovered from his injuries, and the thoracic endograft shows no evidence of endoleak 7 months after treatment. CONCLUSIONS Endoluminal techniques can be used successfully in the immediate repair of thoracic aortic injuries.
Collapse
Affiliation(s)
- A C Lobato
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, Phoenix 85006, USA
| | | | | | | | | | | | | |
Collapse
|
24
|
Abstract
The internal mammary artery is the preferred conduit for coronary bypass grafting; however, suboptimal flow through the internal mammary artery is sometimes found during the operation, and the conduit is abandoned. Subclavian artery stenosis, a well-recognized cause of reduced internal mammary artery flow, is easily and effectively treated with endovascular techniques. We describe a case of intraoperative primary stent deployment in a high-grade subclavian artery stenosis compromising internal mammary artery flow.
Collapse
Affiliation(s)
- M Vranic
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute and Arizona Heart Hospital, Phoenix 85006, USA
| | | | | | | | | |
Collapse
|
25
|
Lopez-Galarza LA, Ray LI, Rodriguez-Lopez J, Diethrich EB. Combined percutaneous transluminal angioplasty, iliac stent deployment, and femorofemoral bypass for bilateral aortoiliac occlusive disease. J Am Coll Surg 1997; 184:249-58. [PMID: 9060920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND We examine the technique of combining percutaneous transluminal angioplasty and secondary intravascular stent deployment with femorofemoral bypass graft in patients with bilateral aortoiliac occlusive disease. STUDY DESIGN Retrospective review. RESULTS During the 5-year period from June 1988 to October 1993, 18 patients with iliac occlusion and a hemodynamically significant contralateral iliac stenosis were treated using a combination of endovascular and open surgical techniques. Patients (13 men and 5 women) ranged in age from 50 to 78 years (mean, 64 years). Thirteen patients (72 percent) were treated for claudication, and 5 patients (28 percent) for rest pain or ulceration. Residual intra-arterial pressure gradients following percutaneous transluminal angioplasty or significant postpercutaneous transluminal angioplasty dissection were the indications for stent deployment in 15 and 3 patients, respectively. No operative deaths occurred, but 3 patients (16 percent) had early complications. Primary patency, as determined by life table analysis, was 100 percent, 79 percent, 62 percent, and 51 percent at 1, 2, 3, and 5 years, respectively. Secondary patency at 1, 2, 3, and 5 years was 100 percent, 93 percent, 75 percent, and 63 percent, respectively, with a mean follow-up of 41 months. CONCLUSIONS The combination of percutaneous transluminal angioplasty with primary or secondary stent deployment and femorofemoral bypass can be a useful option for treating iliac occlusion and contralateral iliac stenosis of less than 3 cm in length when the severity of the comorbid illnesses, advanced age, or the presence of prohibitive intra-abdominal pathology makes the avoidance of an abdominal incision desirable.
Collapse
Affiliation(s)
- L A Lopez-Galarza
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, Phoenix 85006, USA
| | | | | | | |
Collapse
|
26
|
Martinez R, Rodriguez-Lopez J, Torruella L, Ray L, Lopez-Galarza L, Diethrich EB. Stenting for occlusion of the subclavian arteries. Technical aspects and follow-up results. Tex Heart Inst J 1997; 24:23-7. [PMID: 9068135 PMCID: PMC325393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the results of stenting in 17 patients who underwent treatment for total occlusions in the subclavian arteries between July 1991 and December 1995. Fourteen of the lesions were located in the left side; 15 patients had a subclavian steal syndrome. The indications for treatment were vertebrobasilar insufficiency (n = 7); arm claudication (n = 5); vertebrobasilar insufficiency and upper-limb ischemia (n = 3); protection of a left internal mammary artery coronary bypass (n = 1); and an isolated subclavian steal syndrome (n = 1). A total of 23 stents were implanted in 17 patients; in 1 patient, 2 stents migrated during deployment, resulting in a 94% procedural success rate. One case of axillary thrombosis was successfully treated with local thrombolysis and balloon angioplasty. There were no postprocedural neurologic complications or deaths. Follow-up over a mean duration of 19.4 months (range, 4 to 56 months) revealed 1 asymptomatic restenosis at 5 months in a patient with 3 stents. Life-table analysis showed an 81% cumulative patency rate at 6 months. We conclude that stenting for occlusion of the subclavian arteries appears feasible and safe; however, further evaluation in a larger group of patients is needed to confirm these results.
Collapse
Affiliation(s)
- R Martinez
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, Phoenix 85006, USA
| | | | | | | | | | | |
Collapse
|
27
|
Martinez R, Rodriguez-Lopez J, Diethrich EB. Stenting for abdominal aortic occlusive disease. Long-term results. Tex Heart Inst J 1997; 24:15-22. [PMID: 9068134 PMCID: PMC325392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report the long-term results of abdominal aortic stenting in 24 patients who underwent stenting for atherosclerotic occlusive disease (16 stenoses, 6 occlusions, and 2 ulcerative plaques). The occlusions were treated initially with thrombolytic therapy, and all lesions were balloon dilated. Indications for stenting were: residual gradient (n = 10); recoil (n = 7); dissection (n = 2); and atherosclerotic debris (n = 5). Thirty-eight Palmaz stents were implanted in the aorta, and 21 were implanted in the common iliac (n = 19) and external iliac (n = 2) arteries. Technical and clinical success was 100%. Over a mean follow-up period of 48 months (range, 1 to 67 months), 2 patients died and 2 were lost to follow-up. Two patients developed symptoms referable to the aorta (at 43 and 67 months), and each was managed successfully via an endovascular approach. There was no in-stent restenosis. Life-table analysis showed a 100% cumulative primary patency at 5 years. We conclude that stenting for abdominal aortic occlusive disease appears to offer long-term patency slightly superior to that of classical surgical intervention. Aortic stents also do not appear to be subject to restenosis. Follow-up in a larger patient cohort is needed to confirm these observations.
Collapse
Affiliation(s)
- R Martinez
- Department of Cardiovascular and Endovascular Surgery, Arizona Heart Institute, Phoenix 85006, USA
| | | | | |
Collapse
|