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Li HT, Yuan P, Jiang R, Zhao QH, Sun YY, Zhang J, Gong SG, Li JL, Qiu HL, Wu WH, Luo CJ, Xu J, Wang L, Liu JM. Sleep-disordered breathing and nocturnal hypoxemia in chronic thromboembolic pulmonary disease. Intern Med J 2024. [PMID: 38563467 DOI: 10.1111/imj.16359] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 02/25/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND AND AIMS Sleep-disordered breathing (SDB) and nocturnal hypoxemia were known to be present in patients with chronic thromboembolic pulmonary hypertension (CTEPH), but the difference between SDB and nocturnal hypoxemia in patients who have chronic thromboembolic pulmonary disease (CTEPD) with or without pulmonary hypertension (PH) at rest remains unknown. METHODS Patients who had CTEPH (n = 80) or CTEPD without PH (n = 40) and who had undergone sleep studies from July 2020 to October 2022 at Shanghai Pulmonary Hospital were enrolled. Nocturnal mean SpO2 (Mean SpO2) <90% was defined as nocturnal hypoxemia, and the percentage of time with a saturation below 90% (T90%) exceeding 10% was used to evaluate the severity of nocturnal hypoxemia. Logistic and linear regression analyses were performed to investigate the difference and potential predictor of SDB or nocturnal hypoxemia between CTEPH and CTEPD without PH. RESULTS SDB was similarly prevalent in CTEPH and CTEPD without PH (P = 0.104), both characterised by obstructive sleep apnoea (OSA). Twenty-two patients with CTEPH were diagnosed with nocturnal hypoxemia, whereas only three were diagnosed with CTEPD without PH (P = 0.021). T90% was positively associated with mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance in patients with CTEPH and CTEPD without PH (P < 0.001); T90% was also negatively related to cardiac output in these patients. Single-breath carbon monoxide diffusing capacity, sex and mPAP were all correlated with nocturnal hypoxemia in CTEPH and CTEPD without PH (all P < 0.05). CONCLUSION Nocturnal hypoxemia was worse in CTEPD with PH; T90%, but not SDB, was independently correlated with the hemodynamics in CTEPD with or without PH.
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Affiliation(s)
- Hui-Ting Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ping Yuan
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Rong Jiang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Qin-Hua Zhao
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yuan-Yuan Sun
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jian Zhang
- Department of Respiratory and Critical Care Medicine, the 416 Hospital of Nuclear Industry/the Second Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan, China
| | - Su-Gang Gong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Ling Li
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hong-Ling Qiu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Wen-Hui Wu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Ci-Jun Luo
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jiang Xu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lan Wang
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jin-Ming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, School of Medicine, Tongji University, Shanghai, China
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Ghio S, Corsico A, Rapagnani A, Borrelli E, Alloni A, Valentini A, Piloni D, Scelsi L, Klersy C, D'Armini AM. Does pulmonary endarterectomy improve the clinical conditions of patients with chronic thromboembolic pulmonary disease without pulmonary hypertension? J Heart Lung Transplant 2024; 43:681-685. [PMID: 38184125 DOI: 10.1016/j.healun.2023.12.015] [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: 10/31/2023] [Revised: 12/24/2023] [Accepted: 12/27/2023] [Indexed: 01/08/2024] Open
Abstract
To verify whether the new hemodynamic definition of pulmonary hypertension (PH) has any implication in treatment of Chronic Thrombo-Embolic Pulmonary Disease (CTEPD) patients without PH, we retrospectively analysed the clinical and functional changes determined by pulmonary endarterectomy (PEA) in 63 CTEPD patients without PH who underwent surgery at our center, comparing those in whom the hemodynamic diagnosis of PH met recent guideline recommendations versus those in whom the diagnosis only met previous hemodynamic thresholds. The results show that the vast majority of CTEPD patients without PH operated at our center would now be defined as chronic thromboembolic pulmonary hypertension (CTEPH) patients. PEA did not result in any improvement in exercise capacity nor in right ventricular function or lung function test in patients with mean pulmonary artery pressure (mPAP) ≤ 20 mm Hg and pulmonary vascular resistance (PVR) ≤ 2 WU; on the contrary, hemodynamic parameters, exercise capacity, right ventricular function and lung function significantly improved in patients with mPAP between 21 and 24 mm Hg.
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Affiliation(s)
- Stefano Ghio
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Angelo Corsico
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, Pavia, Italy; Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Andrea Rapagnani
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Ermelinda Borrelli
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy
| | - Alessia Alloni
- Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Adele Valentini
- Institut of Radiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Davide Piloni
- Division of Respiratory Diseases, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Laura Scelsi
- Division of Cardiology, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Catherine Klersy
- Service of Clinical Epidemiology and Biometry, Foundation IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Maria D'Armini
- Department of Clinical, Surgical, Pediatric and Diagnostic Sciences, University of Pavia School of Medicine, Italy; Division of Cardiac Surgery 2 and Pulmonary Hypertension Center, Foundation IRCCS Policlinico San Matteo, Pavia, Italy.
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Kim MS, Jeon K, Kim EK, Park TK, Park HY, Yang JH, Park SJ, Lee SC, Park SW, Kim DK, Chang SA. Usefulness of cardiopulmonary exercise test combined with exercise stress echocardiography in mild chronic thromboembolic pulmonary disease. Echocardiography 2024; 41:e15795. [PMID: 38506279 DOI: 10.1111/echo.15795] [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: 12/27/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/21/2024] Open
Abstract
PURPOSE Chronic thromboembolic pulmonary disease (CTEPD) can lead to exercise limitations even without right ventricular (RV) dysfunction or pulmonary hypertension at rest. Combining exercise stress echocardiography with cardiopulmonary exercise testing (ESE-CPET) for RV function and pressure changes combined measuring overall function may be useful for CTEPD evaluation. This study aims to investigate CPET and ESE results to elucidate the mechanisms of exercise limitation in mild CTEPD cases. METHODS Among our CTEPD registry, 50 patients who performed both right heart catheterization data of mild disease (less than 30 mm Hg of mean pulmonary arterial pressure (mPAP)) and ESE-CPET were enrolled. Echocardiography and CPET-derived parameters were compared with hemodynamic parameters measured through right heart catheterization. RESULTS Peak VO2 (maximal oxygen consumption) was decreased in overall population (71.3 ± 16.3% of predictive value). Peak VO2 during exercise was negatively correlate with mPAP and pulmonary vascular resistance at rest. A substantial increase in RV systolic pressure (RVSP) was observed during exercise (RVSP: pre-exercise 37.2 ± 11.8 mm Hg, postexercise 64.3 ± 24.9 mm Hg, p-value < .001). Furthermore, RV function deteriorated during exercise when compared to the baseline (RV fractional area change: 31.5 ± 10.0% to 37.8 ± 7.0%, p-value < .001; RV global longitudinal strain: -17.1 ± 4.2% to -17.7 ± 3.3%, p-value < .001) even though basal RV function was normal. While an excessive increase in RVSP during exercise was noticed in both groups, dilated RV and RV dysfunction during exercise were demonstrated only in the impaired exercise capacity group. CONCLUSION CTEPD patients with mild PH or without PH exhibited limited exercise capacity alongside an excessive increase in RVSP during exercise. Importantly, RV dysfunction during exercise was significantly associated with exercise capacity. ESE-CPET could aid in comprehending the primary cause of exercise limitation in these patients.
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Affiliation(s)
- Min Sun Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Division of Cardiology, Department of Medicine, Biomedical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Kina Jeon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Eun Kyoung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hye Yun Park
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Pulmonary Hypertension Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Seung Woo Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Division of Cardiology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Sung-A Chang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Imaging Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
- Division of Cardiology, Department of Medicine, Pulmonary Hypertension Center, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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Yamaguchi T, Ehara S, Yoshida H, Himoto D, Izuta S, Hayashi O, Hayashi H, Ogawa M, Shibata A, Yamazaki T, Izumiya Y, Fukuda D. Quantification of pulmonary perfusion using LSIM-CT correlates with pulmonary hemodynamics in patients with CTEPD. Front Cardiovasc Med 2023; 10:1237296. [PMID: 38028450 PMCID: PMC10654960 DOI: 10.3389/fcvm.2023.1237296] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 10/04/2023] [Indexed: 12/01/2023] Open
Abstract
Background Lung subtraction iodine mapping (LSIM)-CT is a clinically useful technique that can visualize pulmonary mal-perfusion in patients with chronic thromboembolic pulmonary disease (CTEPD). However, little is known about the associations of LSIM images with hemodynamic parameters of patients with CTEPD. This study investigates a parameter of LSIM images associated with mean pulmonary arterial pressure (mPAP) and validates the association between pulmonary vascular resistance, right atrial pressure, cardiac index, and exercise capacity in patients with CTEPD. Methods This single-center, prospective, observational study involved 30 patients diagnosed with CTEPD using lung perfusion scintigraphy. To examine the correlation of decreased pulmonary perfusion area (DPA) with mPAP, areas with 0-10, 0-15, 0-20, and 0-30 HU in lung subtraction images were adopted in statistical analysis. The DPA to total lung volume ratio (DPA ratio, %) was calculated as the ratio of each DPA volume to the total lung volume. To assess the correlation between DPA ratios of 0-10, 0-15, 0-20, and 0-30 HU and mPAP, Spearman's rank correlation coefficient was used. Results The DPA ratio of 0-10 HU had the most preferable correlation with mPAP than DPA ratios of 0-15, 0-20, and 0-30 HU (ρ = 0.440, P = 0.015). The DPA ratio of 0-10 HU significantly correlates with pulmonary vascular resistance (ρ = 0.445, P = 0.015). The receiver operating characteristic curve analysis indicated that the best cutoff value of the DPA ratio of 0-10 HU for the prediction of an mPAP of ≥30 mmHg was 8.5% (AUC, 0.773; 95% CI, 0.572-0.974; sensitivity, 83.3%; specificity, 75.0%). Multivariate linear regression analysis, which was adjusted for the main pulmonary arterial to ascending aortic diameter ratio and right ventricular to left ventricular diameter ratio, indicated that the DPA ratio of 0-10 HU was independently and significantly associated with mPAP (B = 89.7; 95% CI, 46.3-133.1, P < 0.001). Conclusion The DPA ratio calculated using LSIM-CT is possibly useful for estimating the hemodynamic status in patients with CTEPD.
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Affiliation(s)
- Tomohiro Yamaguchi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shoichi Ehara
- Department of Intensive Care Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Himoto
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Shinichiro Izuta
- Department of Radiology, Osaka Metropolitan University Hospital, Osaka, Japan
| | - Ou Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroya Hayashi
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Mana Ogawa
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Atsushi Shibata
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Takanori Yamazaki
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Daiju Fukuda
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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Yang JZ, Poch DS, Ang L, Mahmud E, Kim NH. Balloon pulmonary angioplasty in the current era of CTEPH treatment: How did we get here? Pulm Circ 2023; 13:e12312. [PMID: 38027455 PMCID: PMC10661326 DOI: 10.1002/pul2.12312] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 11/06/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved pulmonary embolism. The treatment of choice is pulmonary thromboendarterectomy (PTE) surgery and all patients should be evaluated for operability candidacy. Despite advancements in PTE technique allowing more segmental-subsegmental surgeries, up to a third of patients with CTEPH may still be considered inoperable. Over the past decade, there have been increasing treatment options for these inoperable CTEPH patients. Balloon pulmonary angioplasty (BPA) is a percutaneous-based interventional treatment option for select CTEPH cases. Early BPA experiences were plagued by high complication rates, but further refinements in technique and equipment pioneered by Japan led to the worldwide spread and adoption of BPA. Multiple centers have shown that patients experience significant improvements in hemodynamics, quality of life, exercise capacity, and survival with BPA treatment. There remain many questions on best practices, but BPA has evolved into a pivotal cornerstone of CTEPH treatment.
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Affiliation(s)
- Jenny Z. Yang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
| | - David S. Poch
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Lawrence Ang
- Department of Medicine, Division of Cardiovascular MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Ehtisham Mahmud
- Department of Medicine, Division of Cardiovascular MedicineUC San DiegoLa JollaCaliforniaUSA
| | - Nick H. Kim
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep MedicineUC San DiegoLa JollaCaliforniaUSA
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Banaszkiewicz M, Kurzyna P, Kubikowska N, Mucha M, Rudnik A, Gąsecka A, Pietrasik A, Grabowski M, Jaguszewski MJ, Kasprzyk P, Kędzierski P, Ciećwierz D, Żuk G, Szwed P, Piłka M, Florczyk M, Kurzyna M, Darocha S. Emerging Role of Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease-Insights from the 2022 ESC Guidelines. J Clin Med 2023; 12:5336. [PMID: 37629379 PMCID: PMC10455782 DOI: 10.3390/jcm12165336] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023] Open
Abstract
In this article, we discuss the topic of chronic thromboembolic pulmonary disease (CTEPD) and the growing role of balloon pulmonary angioplasty (BPA) in its treatment. We present the pathophysiology of CTEPD which arises from an incomplete resolution of thrombi in the pulmonary arteries and leads to stenosis and occlusion of the vessels. The article focuses mainly on the chronic thromboembolic pulmonary hypertension (CTEPH) subpopulation for which prognosis is very poor when left untreated. We describe a multimodal approach to treating CTEPH, including pulmonary endarterectomy (PEA), BPA, and pharmacological therapies. Additionally, the benefits of pharmacological pre-treatment before BPA and the technical aspects of the procedure itself are outlined. It is emphasized that BPA does not replace PEA but serves as a complementary treatment option for eligible patients. We summarized efficacy and treatment goals including an improvement in functional and biochemical parameters before and after BPA. Patients who received pre-treatment with riociguat prior to BPA exhibited a notable reduction in the occurrence of less severe complications. However, elderly patients are still perceived as an especially vulnerable group. It is shown that the prognosis of patients undergoing BPA is similar to PEA in the first years after the procedure but the long-term prognosis of BPA still remains unclear. The 2022 ESC/ERS guidelines highlight the significant role of BPA in the multimodal treatment of CTEPH, emphasizing its effectiveness and recommending its consideration as a therapeutic option for patients with CTEPD, both with and without pulmonary hypertension. This review summarizes the available evidence for BPA, patient selection, procedural details, and prognosis and discusses the potential future role of BPA in the management of CTEPH.
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Affiliation(s)
- Marta Banaszkiewicz
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Paweł Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Nina Kubikowska
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Magda Mucha
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksander Rudnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-091 Warszawa, Poland
| | | | - Piotr Kasprzyk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Kędzierski
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Dariusz Ciećwierz
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Grzegorz Żuk
- 1st Department of Cardiology, Medical University of Gdansk, 80-210 Gdansk, Poland
| | - Piotr Szwed
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Piłka
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Michał Florczyk
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Marcin Kurzyna
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Szymon Darocha
- Chair and Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, ERN-LUNG Member, 05-400 Otwock, Poland
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Dzikowska-Diduch O, Kurnicka K, Lichodziejewska B, Dudzik-Niewiadomska I, Machowski M, Roik M, Wiśniewska M, Siwiec J, Staniszewska IM, Pruszczyk P. Electrocardiogram, Echocardiogram and NT-proBNP in Screening for Thromboembolism Pulmonary Hypertension in Patients after Pulmonary Embolism. J Clin Med 2022; 11:jcm11247369. [PMID: 36555985 PMCID: PMC9784264 DOI: 10.3390/jcm11247369] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 10/31/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The annual mortality of patients with untreated chronic thromboembolism pulmonary hypertension (CTEPH) is approximately 50% unless a timely diagnosis is followed by adequate treatment. In pulmonary embolism (PE) survivors with functional limitation, the diagnostic work-up starts with echocardiography. It is followed by lung scintigraphy and right heart catheterization. However, noninvasive tests providing diagnostic clues to CTEPH, or ascertaining this diagnosis as very unlikely, would be extremely useful since the majority of post PE functional limitations are caused by deconditioning. Methods: Patients after acute PE underwent a structured clinical evaluation with electrocardiogram, routine laboratory tests including NT-proBNP and echocardiography. The aim of this study was to verify whether the parameters from echocardiographic or perhaps electrocardiographic examination and NT-proBNP concentration best determine the risk of CTEPH. Results: Out of the total number of patients (n = 261, male n = 123) after PE who were included in the study, in the group of 155 patients (59.4%) with reported functional impairment, 13 patients (8.4%) had CTEPH and 7 PE survivors had chronic thromboembolic pulmonary disease (CTEPD) (4.5%). Echo parameters differed significantly between CTEPH/CTEPD cases and other symptomatic PE survivors. Patients with CTEPH/CTEPD also had higher levels of NT-proBNP (p = 0.022) but concentration of NT-proBNP above 125 pg/mL did not differentiate patients with CTEPH/CTEPD (p > 0.05). Additionally, the proportion of patients with right bundle brunch block registered in ECG was higher in the CTEPH/CTED group (23.5% vs. 5.8%, p = 0.034) but there were no differences between the other ECG characteristics of right ventricle overload. Conclusions: Screening for CTEPH/CTEPD should be performed in patients with reduced exercise tolerance compared to the pre PE period. It is not effective in asymptomatic PE survivors. Patients with CTEPH/CTED predominantly had abnormalities indicating chronic thromboembolism in the echocardiographic assessment. NT-proBNP and electrocardiographic characteristics of right ventricle overload proved to be insufficient in predicting CTEPH/CTEPD development.
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Affiliation(s)
- Olga Dzikowska-Diduch
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
- Correspondence: ; Tel.: +48-22-502-11-44; Fax: +48-22-502-21-42
| | - Katarzyna Kurnicka
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Iwona Dudzik-Niewiadomska
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Michał Machowski
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Marek Roik
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Małgorzata Wiśniewska
- 1st Department of Radiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | - Jan Siwiec
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
| | | | - Piotr Pruszczyk
- Department of Internal Medicine & Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland
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Ewert R, Ittermann T, Schmitt D, Pfeuffer-Jovic E, Stucke J, Tausche K, Halank M, Winkler J, Hoheisel A, Stubbe B, Heine A, Seyfarth HJ, Opitz C, Habedank D, Wensel R, Held M. Prognostic Relevance of Cardiopulmonary Exercise Testing for Patients with Chronic Thromboembolic Pulmonary Hypertension. J Cardiovasc Dev Dis 2022; 9:jcdd9100333. [PMID: 36286285 PMCID: PMC9604581 DOI: 10.3390/jcdd9100333] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 09/25/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
Abstract
Background: Following acute pulmonary embolism (PE), a relevant number of patients experience decreased exercise capacity which can be associated with disturbed pulmonary perfusion. Cardiopulmonary exercise testing (CPET) shows several patterns typical for disturbed pulmonary perfusion. Research question: We aimed to examine whether CPET can also provide prognostic information in chronic thromboembolic pulmonary hypertension (CTEPH). Study Design and Methods: We performed a multicenter retrospective chart review in Germany between 2002 and 2020. Patients with CTEPH were included if they had ≥6 months of follow-up and complete CPET and hemodynamic data. Symptom-limited CPET was performed using a cycle ergometer (ramp or Jones protocol). The association of anthropometric data, comorbidities, symptoms, lung function, and echocardiographic, hemodynamic, and CPET parameters with survival was examined. Mortality prediction models were calculated by Cox regression with backward selection. Results: 345 patients (1532 person-years) were included; 138 underwent surgical treatment (pulmonary endarterectomy or balloon pulmonary angioplasty) and 207 received only non-surgical treatment. During follow-up (median 3.5 years), 78 patients died. The death rate per 1000 person-years was 24.9 and 74.2 in the surgical and non-surgical groups, respectively (p < 0.001). In age- and sex-adjusted Cox regression analyses, CPET parameters including peak oxygen uptake (VO2peak, reflecting cardiopulmonary exercise capacity) were prognostic in the non-surgical group but not in the surgical group. In mortality prediction models, age, sex, VO2peak (% predicted), and carbon monoxide transfer coefficient (% predicted) showed significant prognostic relevance in both the overall cohort and the non-surgical group. In the non-surgical group, Kaplan−Meier analysis showed that patients with VO2peak below 53.4% predicted (threshold identified by receiver operating characteristic analysis) had increased mortality (p = 0.007). Interpretation: The additional measurement of cardiopulmonary exercise capacity by CPET allows a more precise prognostic evaluation in patients with CTEPH. CPET might therefore be helpful for risk-adapted treatment of CTEPH.
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Affiliation(s)
- Ralf Ewert
- Internal Medicine B, Pneumology, University Hospital Greifswald, 17475 Greifswald, Germany
| | - Till Ittermann
- Department of Community Medicine, University Hospital Greifswald, 17489 Greifswald, Germany
| | - Delia Schmitt
- Department of Internal Medicine, Medical Missio Hospital, 97074 Würzburg, Germany
| | - Elena Pfeuffer-Jovic
- Department of Internal Medicine, Medical Missio Hospital, 97074 Würzburg, Germany
| | - Johannes Stucke
- Internal Medicine, Pneumology, University Hospital Dresden, 01307 Dresden, Germany
| | - Kristin Tausche
- Internal Medicine, Pneumology, University Hospital Dresden, 01307 Dresden, Germany
| | - Michael Halank
- Internal Medicine, Pneumology, University Hospital Dresden, 01307 Dresden, Germany
| | | | - Andreas Hoheisel
- Department of Pneumology, Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Beate Stubbe
- Internal Medicine B, Pneumology, University Hospital Greifswald, 17475 Greifswald, Germany
- Correspondence:
| | - Alexander Heine
- Internal Medicine B, Pneumology, University Hospital Greifswald, 17475 Greifswald, Germany
| | - Hans-Jürgen Seyfarth
- Internal Medicine, Pneumology, University Hospital Leipzig, 04103 Leipzig, Germany
| | - Christian Opitz
- Internal Medicine, Cardiology, DRK-Hospital Berlin, 14050 Berlin, Germany
| | - Dirk Habedank
- Internal Medicine B, Pneumology, University Hospital Greifswald, 17475 Greifswald, Germany
- Internal Medicine, Cardiology, DRK-Hospital Berlin, 14050 Berlin, Germany
| | - Roland Wensel
- Internal Medicine, Cardiology, DRK-Hospital Berlin, 14050 Berlin, Germany
| | - Matthias Held
- Department of Internal Medicine, Medical Missio Hospital, 97074 Würzburg, Germany
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Pereira AR, Calé R, Ferreira F, Alegria S, Vitorino S, Loureiro MJ, Pereira H. Balloon Pulmonary Angioplasty of a Chronic Total Occlusion: Procedure Guided by Intravascular Ultrasound. JACC Cardiovasc Interv 2021; 14:e23-5. [PMID: 33454295 DOI: 10.1016/j.jcin.2020.10.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/20/2020] [Indexed: 11/22/2022]
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11
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Rivera-Lebron BN, Rali PM, Tapson VF. The PERT Concept: A Step-by-Step Approach to Managing Pulmonary Embolism. Chest 2020; 159:347-355. [PMID: 32758561 DOI: 10.1016/j.chest.2020.07.065] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [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: 03/18/2020] [Revised: 05/30/2020] [Accepted: 07/16/2020] [Indexed: 11/28/2022] Open
Abstract
Pulmonary embolism (PE) is a major source of morbidity and mortality. The presentation of acute PE varies, ranging from few or no symptoms to sudden death. Patient outcome depends on how well the right ventricle can sustain the increased afterload caused by the embolic burden. Careful risk stratification is critical, and the PE response team (PERT) concept offers a rapid and multidisciplinary approach. Anticoagulation is essential unless contraindicated; thrombolysis, surgical embolectomy, and catheter-directed approaches are also available. Clinical consensus statements have been published that offer a guide to PE management, but areas remain for which the evidence is inadequate. Although the management of low-risk and high-risk patients is more straightforward, optimal management of intermediate-risk patients remains controversial. In this document, we offer a case-based approach to PE management, beginning with diagnosis and risk stratification, followed by therapeutic alternatives, and finishing with follow-up care.
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Affiliation(s)
- Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.
| | - Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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