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Liley J, Newnham M, Bleda M, Bunclark K, Auger W, Barbera JA, Bogaard H, Delcroix M, Fernandes TM, Howard L, Jenkins D, Lang I, Mayer E, Rhodes C, Simpson M, Southgate L, Trembath R, Wharton J, Wilkins MR, Gräf S, Morrell N, Zaba JP, Toshner M. Shared and Distinct Genomics of Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Embolism. Am J Respir Crit Care Med 2024; 209:1477-1485. [PMID: 38470220 DOI: 10.1164/rccm.202307-1236oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 03/11/2024] [Indexed: 03/13/2024] Open
Abstract
Rationale: Chronic thromboembolic pulmonary hypertension involves the formation and nonresolution of thrombus, dysregulated inflammation, angiogenesis, and the development of a small-vessel vasculopathy. Objectives: We aimed to establish the genetic basis of chronic thromboembolic pulmonary hypertension to gain insight into its pathophysiological contributors. Methods: We conducted a genome-wide association study on 1,907 European cases and 10,363 European control subjects. We coanalyzed our results with existing results from genome-wide association studies on deep vein thrombosis, pulmonary embolism, and idiopathic pulmonary arterial hypertension. Measurements and Main Results: Our primary association study revealed genetic associations at the ABO, FGG, F11, MYH7B, and HLA-DRA loci. Through our coanalysis, we demonstrate further associations with chronic thromboembolic pulmonary hypertension at the F2, TSPAN15, SLC44A2, and F5 loci but find no statistically significant associations shared with idiopathic pulmonary arterial hypertension. Conclusions: Chronic thromboembolic pulmonary hypertension is a partially heritable polygenic disease, with related though distinct genetic associations with pulmonary embolism and deep vein thrombosis.
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Affiliation(s)
| | - Michael Newnham
- Institute of Applied Health Research, Birmingham, United Kingdom
| | - Marta Bleda
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - William Auger
- University of California, San Diego, San Diego, California
| | - Joan Albert Barbera
- Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Centro de Investigación Biomédica en Red Enfermedades Respiratorias, University of Barcelona, Barcelona, Spain
| | - Harm Bogaard
- Amsterdam University Medical Center, Amsterdam, the Netherlands
| | | | | | - Luke Howard
- Hammersmith Hospital, London, United Kingdom
| | | | - Irene Lang
- Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | | | | | | | | | | | - John Wharton
- St. George's, University of London, London, United Kingdom
| | | | - Stefan Gräf
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nicholas Morrell
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | | | - Mark Toshner
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
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Bertici RA, Bertici NS, Ridichie A, Fira-Mladinescu O. Comorbidities, Treatment and Survival Rates of Chronic Thromboembolic Pulmonary Hypertension in a Regional Centre. J Clin Med 2024; 13:2754. [PMID: 38792295 PMCID: PMC11122045 DOI: 10.3390/jcm13102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/24/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by a multitude of underlying causes, treatment modalities and prognostic outcomes. Our aim was to evaluate the underlying causes, comorbidities and survival rates of CTEPH patients. Methods: A retrospective analysis was conducted regarding the evolution of CTEPH patients confirmed by right heart catheterization under treatment with specific vasodilator medication in our centre between 2008 and 2023. Results: We treated 14 CTEPH patients, 78.57% female, 52.79 ± 13.64 years at inclusion, representing 11.29% of our pulmonary arterial hypertension registry. Initially, the distribution of patients' NYHA class was II-14.28%, III-71.42% and IV-14.28%. In total, 71.42% of these patients were technically operable due to the central location of the thrombus, but 42.85% presented severe comorbidities and 28.57% refused the surgery or it was financially inaccessible. Only four patients were operated on by pulmonary endarterectomy (PEA). Unfortunately, all the post-PEA patients had persistent pulmonary hypertension and had to continue vasodilator treatment. Overall, 64.28% of patients had monotherapy, 21.42% double therapy and 14.28% triple therapy. Regarding underlying causes and comorbidities, we found the following incidences: 78.57% chronic venous insufficiency, 42.85% obesity, 35.71% thyroid disease, hypertension and hyperuricemia, 21.42% thrombophilia and ischemic heart disease, 14.28% atrial fibrillation, vasculitis and lung disease, and 14.28% neoplastic history and diabetes. Seven patients died (50%), six of whom were unoperated and one of whom was lost (abandoned the program). The survival rates at 1, 3, 5 and 7 years for unoperated patients were 100%, 58.3%, 29.2% and 29.2% versus 100%, 75%, 75% and 75% in post-PEA patients. Conclusions: CTEPH, marked by delayed diagnosis, multiple comorbidities and limited intervention options, requires proactive screening and comprehensive multimodal therapies, including PEA, to improve survival rates.
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Affiliation(s)
- Razvan Adrian Bertici
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
| | - Nicoleta Sorina Bertici
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
- Clinical Hospital of Infectious Diseases and Pulmonology Victor Babes Timisoara, Gheorghe Adam Street 13, 300310 Timisoara, Romania
| | - Amalia Ridichie
- Advanced Instrumental Screening Center, Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania;
| | - Ovidiu Fira-Mladinescu
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
- Clinical Hospital of Infectious Diseases and Pulmonology Victor Babes Timisoara, Gheorghe Adam Street 13, 300310 Timisoara, Romania
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3
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Kachabi A, Colebank MJ, Chesler NC. Subject-specific one-dimensional fluid dynamics model of chronic thromboembolic pulmonary hypertension. Biomech Model Mechanobiol 2024; 23:469-483. [PMID: 38017302 PMCID: PMC10963496 DOI: 10.1007/s10237-023-01786-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/21/2023] [Indexed: 11/30/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) develops due to the accumulation of blood clots in the lung vasculature that obstructs flow and increases pressure. The mechanobiological factors that drive progression of CTEPH are not understood, in part because mechanical and hemodynamic changes in the small pulmonary arteries due to CTEPH are not easily measurable. Using previously published hemodynamic measurements and imaging from a large animal model of CTEPH, we applied a subject-specific one-dimensional (1D) computational fluid dynamic (CFD) approach to investigate the impact of CTEPH on pulmonary artery stiffening, time-averaged wall shear stress (TAWSS), and oscillatory shear index (OSI) in extralobar (main, right, and left) pulmonary arteries and intralobar (distal to the extralobar) arteries. Our results demonstrate that CTEPH increases pulmonary artery wall stiffness and decreases TAWSS in extralobar and intralobar arteries. Moreover, CTEPH increases the percentage of the intralobar arterial network with both low TAWSS and high OSI, quantified by the novel parameter φ , which is related to thrombogenicity. Our analysis reveals a strong positive correlation between increases in mean pulmonary artery pressure (mPAP) and φ from baseline to CTEPH in individual subjects, which supports the suggestion that increased φ drives disease severity. This subject-specific experimental-computational framework shows potential as a predictor of the impact of CTEPH on pulmonary arterial hemodynamics and pulmonary vascular mechanics. By leveraging advanced modeling techniques and calibrated model parameters, we predict spatial distributions of flow and pressure, from which we can compute potential physiomarkers of disease progression. Ultimately, this approach can lead to more spatially targeted interventions that address the needs of individual CTEPH patients.
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Affiliation(s)
- Amirreza Kachabi
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Mitchel J Colebank
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA
| | - Naomi C Chesler
- Edwards Lifesciences Foundation Cardiovascular Innovation and Research Center, Department of Biomedical Engineering, University of California, Irvine, Irvine, CA, USA.
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In Situ Pulmonary Arterial Thrombosis-Literature Review and Clinical Significance of a Distinct Entity. AJR Am J Roentgenol 2023:1-12. [PMID: 36856299 DOI: 10.2214/ajr.23.28996] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Filling defects identified in the pulmonary arterial tree are commonly presumed to represent an embolic phenomenon originating from thrombi formed in remote veins, particularly lower-extremity deep venous thrombosis (DVT). However, accumulating evidence supports an underappreciated cause for pulmonary arterial thrombosis (PAT), namely, de novo thrombogenesis-where thrombosis arises within the pulmonary arteries in the absence of DVT. Although historically underrecognized, in situ PAT has become of heightened importance with the emergence of SARS-CoV-2 infection. In situ PAT is attributed to endothelial dysfunction, systemic inflammation, and acute lung injury, and has been described in a range of conditions including COVID-19, trauma, acute chest syndrome in sickle cell disease, pulmonary infections, and severe pulmonary arterial hypertension. The distinction between pulmonary embolus and in situ PAT may have important implications regarding management decisions and clinical outcomes. In this review, we summarize the pathophysiology, imaging appearances, and management of in situ PAT in various clinical situations. This understanding will promote optimal tailored treatment strategies for this increasingly recognized entity.
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Nakano Y, Adachi S, Nishiyama I, Yasuda K, Imai R, Yoshida M, Iwano S, Kondo T, Murohara T. Usefulness of a refined computed tomography imaging method to assess the prevalence of residual pulmonary thrombi in patients 1 year after acute pulmonary embolism: The Nagoya PE study. J Thromb Haemost 2022; 20:888-898. [PMID: 35000288 PMCID: PMC9303750 DOI: 10.1111/jth.15636] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-pulmonary embolism (PE) syndrome is an important clinical condition that can affect the long-term prognosis after acute PE. OBJECTIVE We aimed to evaluate the prevalence of residual pulmonary thrombi and the thrombotic burden 1 year after acute PE, by using our refined computed tomography (CT) imaging method. PATIENTS/METHODS In this prospective study, patients diagnosed with acute PE were recruited and examinations were conducted at 1 month, 6 months, and 1 year. Especially at 1 year, patients were evaluated multifacetedly, including by laboratory tests, quality-of-life, 6-min walking test, and enhanced CT. RESULTS Fifty-two patients were enrolled. Two patients (3.8%) developed chronic thromboembolic pulmonary hypertension. A total of 43 patients completed evaluation at 1 year, among whom (74%) had residual thrombi, with a median modified CT obstruction index (mCTOI) of 10.7%. In multivariate analysis, residual thrombi at 1 month was the only factor significantly related to residual thrombi at 1 year (odds ratio, 103.4; 95% confidence interval, 4.2-2542.1). The tricuspid regurgitation pressure gradient ≥60 mmHg and left ventricular end-diastolic dimension at diagnosis were significantly related to mCTOI at 1 year (β = 0.367, P = .003; and β = -0.435, P = .001, respectively). CONCLUSIONS Using our improved CT imaging protocol, we found a high prevalence of residual thrombi 1 year after acute PE. Furthermore, right ventricular overload was related to the thrombotic burden. The long-term treatment strategy of acute PE could be modified to include precise CT imaging.
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Affiliation(s)
- Yoshihisa Nakano
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Shiro Adachi
- Department of CardiologyNagoya University HospitalNagoyaJapan
| | - Itsumure Nishiyama
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | | | - Ryo Imai
- Department of CardiologyNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | | | - Shingo Iwano
- Department of RadiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Takahisa Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
- Department of CardiologyNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
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Sharma S, Lang IM. More Evidence for Inflammatory Thrombosis in Chronic Thromboembolic Pulmonary Hypertension: Is the Embolic Hypothesis Losing Ground? Am J Respir Crit Care Med 2022; 205:745-746. [PMID: 35133253 PMCID: PMC9836223 DOI: 10.1164/rccm.202201-0001ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Smriti Sharma
- Department of Internal Medicine II (Cardiology) Medical University of Vienna Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II (Cardiology) Medical University of Vienna Vienna, Austria
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7
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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Rosen K, Raanani E, Kogan A, Kenet G, Misgav M, Lubetsky A, Niznik S, Schäfers HJ, Segel MJ, Agmon-Levin N. Chronic thromboembolic pulmonary hypertension in patients with antiphospholipid syndrome: Risk factors and management. J Heart Lung Transplant 2021; 41:208-216. [PMID: 34836752 DOI: 10.1016/j.healun.2021.10.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/23/2021] [Accepted: 10/18/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Antiphospholipid syndrome (APS) may cause chronic thromboembolic pulmonary hypertension (CTEPH). Current knowledge regarding prevalence and risk factors for CTEPH among APS patients is limited. We sought to determine clinical features and biomarkers that could identify APS subjects suffering from CTEPH, and describe the prevalence, course and treatment outcomes of patients with APS-CTEPH. METHODS 504 APS patients were treated in our center during 2008 to 2019. We studied clinical and laboratory features of 69 APS patients, comparing 19 patients diagnosed with CTEPH (APS-CTEPH) and treated accordingly, with 50 consecutive age and gender matched patients with no evidence of pulmonary hypertension (APS-No-CTEPH). RESULTS CTEPH prevalence was 3.8% in our APS cohort and was linked with the following parameters: primary APS (p < 0.05); prior pulmonary embolism (p < 0.001); recurrent venous thromboembolism (VTE) (p < 0.001); lower platelet counts (p < 0.001); triple anti-phospholipid antibodies positivity (p < 0.001), higher titers of anti-cardiolipin IgG (p < 0.001), anti-B2GPI IgG (p < 0.001), and high Russell viper venom time ratio (RVVT-ratio) (p < 0.05). Additionally, history of catastrophic APS was more prevalent in APS-CTEPH vs APS-No-CTEPH (p < 0.05). Of APS-CTEPH patients, 15/19 underwent pulmonary endarterectomy (PEA): In 12/15 the procedure was elective and resulted in good perioperative and long-term outcomes, while only 1 of 3 patients that underwent urgent PEA survived. CONCLUSIONS CTEPH is relatively common in APS. Primary APS, prior PE, recurrent VTE, thrombocytopenia and specific anti-phospholipid antibodies predict CTEPH in APS. Active assessment for CTEPH in APS patients should be considered, as PEA was found to be effective and relatively safe, especially if electively performed.
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Affiliation(s)
- Keren Rosen
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel
| | - Ehud Raanani
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Alexander Kogan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Gili Kenet
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; The Israeli National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Mudi Misgav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; The Israeli National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Aharon Lubetsky
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; The Israeli National Hemophilia Center, Sheba Medical Center, Tel Hashomer, Israel
| | - Stanely Niznik
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Michael J Segel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel; Pulmonary Institute, Sheba Medical Center, Tel Hashomer, Israel
| | - Nancy Agmon-Levin
- Clinical Immunology, Angioedema and Allergy Unit, The Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel Hashomer, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv-Yafo, Israel.
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9
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Ebrahimi BS, Tawhai MH, Kumar H, Burrowes KS, Hoffman EA, Wilsher ML, Milne D, Clark AR. A computational model of contributors to pulmonary hypertensive disease: impacts of whole lung and focal disease distributions. Pulm Circ 2021; 11:20458940211056527. [PMID: 34820115 PMCID: PMC8607494 DOI: 10.1177/20458940211056527] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022] Open
Abstract
Pulmonary hypertension has multiple etiologies and so can be difficult to diagnose, prognose, and treat. Diagnosis is typically made via invasive hemodynamic measurements in the main pulmonary artery and is based on observed elevation of mean pulmonary artery pressure. This static mean pressure enables diagnosis, but does not easily allow assessment of the severity of pulmonary hypertension, nor the etiology of the disease, which may impact treatment. Assessment of the dynamic properties of pressure and flow data obtained from catheterization potentially allows more meaningful assessment of the strain on the right heart and may help to distinguish between disease phenotypes. However, mechanistic understanding of how the distribution of disease in the lung leading to pulmonary hypertension impacts the dynamics of blood flow in the main pulmonary artery and/or the pulmonary capillaries is lacking. We present a computational model of the pulmonary vasculature, parameterized to characteristic features of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension to help understand how the two conditions differ in terms of pulmonary vascular response to disease. Our model incorporates key features known to contribute to pulmonary vascular function in health and disease, including anatomical structure and multiple contributions from gravity. The model suggests that dynamic measurements obtained from catheterization potentially distinguish between distal and proximal vasculopathy typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. However, the model suggests a non-linear relationship between these data and vascular structural changes typical of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension which may impede analysis of these metrics to distinguish between cohorts.
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Affiliation(s)
| | - Merryn H. Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Haribalan Kumar
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Kelly S. Burrowes
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Eric A. Hoffman
- Department of Radiology, University of Iowa, Iowa City, IA,
USA
| | - Margaret L. Wilsher
- Respiratory Services, Auckland City Hospital, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland,
Auckland, New Zealand
| | - David Milne
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand
| | - Alys R. Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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Cao Y, Geng C, Li Y, Zhang Y. In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease. Front Pharmacol 2021; 12:671589. [PMID: 34305592 PMCID: PMC8296465 DOI: 10.3389/fphar.2021.671589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.
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Affiliation(s)
- Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chao Geng
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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11
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Zhu YJ, Zhou YP, Wei YP, Xu XQ, Yan XX, Liu C, Zhu XJ, Liu ZY, Sun K, Hua L, Jiang X, Jing ZC. Association Between Anticoagulation Outcomes and Venous Thromboembolism History in Chronic Thromboembolic Pulmonary Hypertension. Front Cardiovasc Med 2021; 8:628284. [PMID: 34095244 PMCID: PMC8175786 DOI: 10.3389/fcvm.2021.628284] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/12/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The association between anticoagulation outcomes and prior history of venous thromboembolism (VTE) in chronic thromboembolic pulmonary hypertension (CTEPH) has not been established. This study aimed to compare the efficacy and safety of anticoagulation treatment in CTEPH patients with and without prior history of VTE. Methods: A total of 333 CTEPH patients prescribed anticoagulants were retrospectively included from May 2013 to April 2019. The clinical characteristics were collected at their first admission. Incidental recurrent VTE and clinically relevant bleeding were recorded during follow-up. The Cox proportional regression models were used to identify potential factors associated with recurrent VTE and clinically relevant bleeding. Results: Seventy patients (21%) without a prior history of VTE did not experience recurrent VTE during anticoagulation. Compared to CTEPH patients without a prior history of VTE, those with a prior history of VTE had an increased risk of recurrent VTE [2.27/100 person-year vs. 0/100 person-year; hazard ratio (HR), 8.92; 95% confidence interval (CI), 1.18–1142.00; P = 0.029] but a similar risk of clinically relevant bleeding (3.90/100 person-year vs. 4.59/100 person-year; HR, 0.83; 95% CI, 0.38–1.78; P = 0.623). Multivariate Cox analyses suggested that a prior history of VTE and interruption of anticoagulation treatments were significantly associated with an increased risk of recurrent VTE, while anemia and glucocorticoid use were significantly associated with a higher risk of clinically relevant bleeding. Conclusions: This study is the first to reveal that a prior history of VTE significantly increases the risk of recurrent VTE in CTEPH patients during anticoagulation treatment. This finding should be further evaluated in prospective studies.
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Affiliation(s)
- Yong-Jian Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu-Ping Zhou
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yun-Peng Wei
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Qi Xu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xi-Jie Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zi-Yi Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kai Sun
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Department of Pulmonary Vascular Disease and Thrombosis Medicine, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, FuWai Hospital, Chinese Academy Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Jiang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhi-Cheng Jing
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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12
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Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J 2020; 55:13993003.00189-2020. [PMID: 32184319 DOI: 10.1183/13993003.00189-2020] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/03/2020] [Indexed: 02/05/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). Untreated CTEPH is fatal, but, if diagnosed in time, successful surgical (pulmonary endarterectomy), medical (pulmonary hypertension drugs) and/or interventional (balloon pulmonary angioplasty) therapies have been shown to improve clinical outcomes, especially in case of successful pulmonary endarterectomy. Early diagnosis has however been demonstrated to be challenging. Poor awareness of the disease by patients and physicians, high prevalence of the post-PE syndrome (i.e. persistent dyspnoea, functional limitations and/or decreased quality of life following an acute PE diagnosis), lack of clear guideline recommendations as well as inefficient application of diagnostic tests in clinical practice lead to a reported staggering diagnostic delay >1 year. Hence, there is a great need to improve current clinical practice and diagnose CTEPH earlier. In this review, we will focus on the clinical presentation of and risk factors for CTEPH, and provide best practices for PE follow-up programmes from expert centres, based on a clinical case.
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Affiliation(s)
- Fredrikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Univ Brest, Brest, France
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals and Respiratory Division, Dept of Chronic Diseases, Metabolism and Aging, KU Leuven - University of Leuven, Leuven, Belgium
| | - Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicêtre, France.,Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France.,INSERM UMR S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
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13
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Yan L, Li X, Liu Z, Zhao Z, Luo Q, Zhao Q, Jin Q, Yu X, Zhang Y. Research progress on the pathogenesis of CTEPH. Heart Fail Rev 2020; 24:1031-1040. [PMID: 31087212 DOI: 10.1007/s10741-019-09802-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an established long-term complication of pulmonary thromboembolism (PTE). However, studies have shown that many patients with a definitive CTEPH diagnosis have no history of symptomatic PTE, suggesting that PTE is not the only cause of CTEPH. Despite extensive progress in research on pulmonary hypertension in recent years, due to a lack of relevant studies on the pathophysiology of CTEPH, implementing pulmonary endarterectomy (PEA) in patients has many challenges, and the prognosis of patients with CTEPH is still not optimistic. Therefore, revealing the pathogenesis of CTEPH would be of great significance for understanding the occurrence and development of CTEPH, developing relevant drug treatment studies and formulating intervention strategies, and may provide new preventive measures. This article summarizes the current research progress in CTEPH pathogenesis from the perspective of risk factors related to medical history, abnormal coagulation and fibrinolytic mechanisms, inflammatory mechanisms, genetic susceptibility factors, angiogenesis, in situ thrombosis, vascular remodeling, and other aspects.
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Affiliation(s)
- Lu Yan
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xin Li
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China.
| | - Zhihui Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qin Zhao
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Qi Jin
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Xue Yu
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
| | - Yi Zhang
- Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167 Beilishi Rd, Xicheng District, Beijing, 100037, China
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14
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Boon GJAM, van Rein N, Bogaard HJ, Ende-Verhaar YM, Huisman MV, Kroft LJM, van der Meer FJM, Meijboom LJ, Symersky P, Vonk Noordegraaf A, Klok FA. Quality of initial anticoagulant treatment and risk of CTEPH after acute pulmonary embolism. PLoS One 2020; 15:e0232354. [PMID: 32343741 PMCID: PMC7188241 DOI: 10.1371/journal.pone.0232354] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 04/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The pathophysiology of chronic thromboembolic pulmonary hypertension (CTEPH) is not fully understood. Poor-quality anticoagulation may contribute to a higher risk of CTEPH after acute pulmonary embolism (PE), partly explaining the transition from acute PE to CTEPH. We assessed the association between the time in therapeutic range (TTR) of vitamin-K antagonist (VKA) treatment and incidence of CTEPH after a PE diagnosis. METHODS Case-control study in which the time spent in, under and above therapeutic range was calculated in 44 PE patients who were subsequently diagnosed with CTEPH (cases). Controls comprised 150 consecutive PE patients in whom echocardiograms two years later did not show pulmonary hypertension. All patients were treated with VKA for at least 6 months after the PE diagnosis. Time in (TTR), under and above range were calculated. Mean differences between cases and controls were estimated by linear regression. RESULTS Mean TTR during the initial 6-month treatment period was 72% in cases versus 78% in controls (mean difference -6%, 95%CI -12 to -0.1), mainly explained by more time above the therapeutic range in the cases. Mean difference of time under range was 0% (95%CI -6 to 7) and 2% (95CI% -3 to 7) during the first 3 and 6 months, respectively. In a multivariable model, adjusted odds ratios (ORs) for CTEPH were around unity considering different thresholds for 'poor anticoagulation', i.e. TTR <50%, <60% and <70%. CONCLUSION Subtherapeutic initial anticoagulation was not more prevalent among PE patients diagnosed with CTEPH than in those who did not develop CTEPH.
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Affiliation(s)
- Gudula J. A. M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Yvonne M. Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J. M. Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J. M. van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, VU University Medical Center, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
- * E-mail:
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15
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Sepúlveda C, Repolho D, Antunes AM, Taulaigo AV, Carreiro F, Ferreira RC, Moraes-Fontes MF, Loureiro MJ. Dyspnea in antiphospholipid syndrome: Beyond pulmonary embolism. Rev Port Cardiol 2020; 39:47.e1-47.e5. [PMID: 32173092 DOI: 10.1016/j.repc.2018.01.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/15/2018] [Indexed: 11/15/2022] Open
Abstract
Pulmonary embolism due to primary antiphospholipid syndrome is rarely associated with chronic thromboembolic pulmonary hypertension, and therefore according to the latest guidelines on pulmonary hypertension, routine screening is not recommended. We describe a young patient with a late diagnosis of chronic thromboembolic pulmonary hypertension in the context of pulmonary embolism, primary antiphospholipid syndrome and suboptimal anticoagulation. Of note, mild cardiopulmonary symptoms were consistently misattributed to a depressive disorder because physical examination was normal, serial Doppler echocardiography failed to show pulmonary hypertension, and all other diagnostic tests were normal. Once symptoms became severe, positive screening tests led to the correct diagnosis and surgical referral, and bilateral pulmonary endarterectomy was successfully performed. This case demonstrates the need for extra awareness in patients with antiphospholipid syndrome and pulmonary embolism.
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Affiliation(s)
- Carolina Sepúlveda
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal; Serviço de Medicina Interna, Hospital de Abrantes - Centro Hospitalar Médio Tejo (CHMT), Abrantes, Portugal.
| | - Débora Repolho
- Unidade de Hipertensão Pulmonar, Serviço de Cardiologia - Hospital Garcia de Orta (HGO), Almada, Portugal
| | - Ana Margarida Antunes
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Anna Viola Taulaigo
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Filipa Carreiro
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal; Serviço de Medicina Interna - Hospital do Divino Espírito Santo (HDES), Ponta Delgada, Portugal
| | - Rui Cruz Ferreira
- Serviço de Cardiologia, Hospital de Santa Marta - CHLC, Lisboa, Portugal
| | - Maria Francisca Moraes-Fontes
- Unidade de Doenças Autoimunes, Medicina 7.2, Hospital Curry Cabral - Centro Hospitalar Lisboa Central (CHLC), Lisboa, Portugal
| | - Maria José Loureiro
- Unidade de Hipertensão Pulmonar, Serviço de Cardiologia - Hospital Garcia de Orta (HGO), Almada, Portugal
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16
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Rashidi F, Parvizi R, Bilejani E, Mahmoodian B, Rahimi F, Koohi A. Evaluation of the Incidence of Chronic Thromboembolic Pulmonary Hypertension 1 Year After First Episode of Acute Pulmonary Embolism: A Cohort Study. Lung 2020; 198:59-64. [PMID: 31894412 DOI: 10.1007/s00408-019-00315-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/23/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Chronic thromboembolic pulmonary hypertension (CTEPH) is an important complication after acute pulmonary embolism (PE) with considerable morbidity and mortality. The aim of this study was to estimate the CTEPH incidence in a cohort after the first occurrence of PE. METHODS We conducted a 1-year follow-up cohort study between 2015 and 2018 to assess the incidence of CTEPH in 474 patients with their first acute episode of PE. For the diagnosis of CTEPH, patients with unexplained persistent dyspnea during follow-up underwent transthoracic echocardiography, right heart catheterization, ventilation-perfusion lung scanning, and CT pulmonary angiography. RESULTS Overall, 317 patients were included in the study. The mean age of the patients was 56.5 ± 16 years. One hundred and three patients (32%) had exertional dyspnea at the 1-year follow-up. Patients with evidence of pulmonary hypertension (PH) on echocardiography underwent right heart catheterization. Eleven patients (18%) had no PH (mPAP < 25 mmHg); 47 patients (81%) had mPAP > 25 mmHg. Fifteen patients had PAWP > 15 mmHg, including those with underlying left heart problems or valvular diseases. There were 32 patients with PAH (mPAP > 25 mmHg and PVR > 3 WU) undergoing CTEPH studies; 22 patients (6.9%) had multiple segmental defects suggesting CTEPH on a perfusion scan. CONCLUSION The incidence of CTEPH observed in this study 1 year after the first episode of acute PE was approximately 6.9%. This incidence seems to be high in our population, and diagnostic and therapeutic strategies for the early identification of CTEPH are needed.
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Affiliation(s)
- Farid Rashidi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran. .,Tabriz University of Medical Sciences, Imam Reza General Hospital, 29 Bahaman St, Tabriz, Iran.
| | - Rezayat Parvizi
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Eisa Bilejani
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Babak Mahmoodian
- Medical Radiation Sciences Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Rahimi
- Department of Radiology, Imam Reza Teaching Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Koohi
- Tuberculosis and Lung Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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17
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Sepúlveda C, Repolho D, Antunes AM, Taulaigo AV, Carreiro F, Ferreira RC, Moraes-Fontes MF, Loureiro MJ. Dyspnea in antiphospholipid syndrome: Beyond pulmonary embolism. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2020. [DOI: 10.1016/j.repce.2018.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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18
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Mahmud E, Madani MM, Kim NH, Poch D, Ang L, Behnamfar O, Patel MP, Auger WR. Chronic Thromboembolic Pulmonary Hypertension: Evolving Therapeutic Approaches for Operable and Inoperable Disease. J Am Coll Cardiol 2019; 71:2468-2486. [PMID: 29793636 DOI: 10.1016/j.jacc.2018.04.009] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 03/19/2018] [Accepted: 04/03/2018] [Indexed: 12/31/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.
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Affiliation(s)
- Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California.
| | - Michael M Madani
- Division of Cardiothoracic Surgery, University of California San Diego, La Jolla, California
| | - Nick H Kim
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - David Poch
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
| | - Lawrence Ang
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Omid Behnamfar
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - Mitul P Patel
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, California
| | - William R Auger
- Division of Pulmonary and Critical Care Medicine, Sulpizio Cardiovascular Center, University of California San Diego, La Jolla, California
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19
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Use of direct oral anticoagulants prevents increase in pulmonary vascular resistance and incidence of clinical worsening in patients with chronic thromboembolic pulmonary hypertension. Thromb Res 2019; 180:43-46. [PMID: 31200342 DOI: 10.1016/j.thromres.2019.05.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 05/23/2019] [Accepted: 05/28/2019] [Indexed: 11/21/2022]
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20
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Albani S, Biondi F, Stolfo D, Lo Giudice F, Sinagra G. Chronic thromboembolic pulmonary hypertension (CTEPH): what do we know about it? A comprehensive review of the literature. J Cardiovasc Med (Hagerstown) 2019; 20:159-168. [PMID: 30720636 DOI: 10.2459/jcm.0000000000000774] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
: Chronic thromboembolic disease (CTED), especially when associated with pulmonary hypertension (CTEPH), is a fearsome and under-diagnosed but potentially curable complication of pulmonary embolism, thanks to recent therapeutic options. Aspecific symptoms and signs make its diagnosis challenging, requiring clinicians to be ready to suspect its presence in patients with dyspnea of unknown origin or persistent symptoms after acute pulmonary embolism. The aim of this review is to provide an update to the general practitioner or the specialist physician on the state of the art regarding the epidemiology, pathophysiology and clinical management of chronic thromboembolic syndromes.
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Affiliation(s)
- Stefano Albani
- Cardiothoracic Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Federico Biondi
- Cardiothoracic Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiothoracic Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, Trieste, Italy
| | - Francesco Lo Giudice
- Pulmonary Hypertension National Service, Hammersmith Hospital Imperial College NHS Trust, London, UK
| | - Gianfranco Sinagra
- Cardiothoracic Department, Division of Cardiology and Postgraduate School in Cardiovascular Sciences, University of Trieste, Trieste, Italy
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21
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Kim NH, Delcroix M, Jais X, Madani MM, Matsubara H, Mayer E, Ogo T, Tapson VF, Ghofrani HA, Jenkins DP. Chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 53:13993003.01915-2018. [PMID: 30545969 PMCID: PMC6351341 DOI: 10.1183/13993003.01915-2018] [Citation(s) in RCA: 395] [Impact Index Per Article: 79.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Accepted: 10/09/2018] [Indexed: 12/15/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and a major cause of chronic PH leading to right heart failure and death. Lung ventilation/perfusion scintigraphy is the screening test of choice; a normal scan rules out CTEPH. In the case of an abnormal perfusion scan, a high-quality pulmonary angiogram is necessary to confirm and define the pulmonary vascular involvement and prior to making a treatment decision. PH is confirmed with right heart catheterisation, which is also necessary for treatment determination. In addition to chronic anticoagulation therapy, each patient with CTEPH should receive treatment assessment starting with evaluation for pulmonary endarterectomy, which is the guideline recommended treatment. For technically inoperable cases, PH-targeted medical therapy is recommended (currently riociguat based on the CHEST studies), and balloon pulmonary angioplasty should be considered at a centre experienced with this challenging but potentially effective and complementary intervention.
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Affiliation(s)
- Nick H Kim
- Dept of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Marion Delcroix
- Dept of Respiratory Diseases, University Hospitals of Leuven and Respiratory Division, Dept CHROMETA, KU Leuven - University of Leuven, Leuven, Belgium
| | - Xavier Jais
- Université Paris-Sud, AP-HP, Centre de Référence de l'Hypertension Pulmonaire, Service de Pneumologie, Département Hospitalo-Universitaire (DHU) Thorax Innovation (TORINO), Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Michael M Madani
- Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Eckhard Mayer
- Kerckhoff Clinic Bad Nauheim, University of Giessen, Bad Nauheim, Germany
| | - Takeshi Ogo
- Division of Advanced Medical Research in Pulmonary Hypertension, Dept of Pulmonary Circulation, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Victor F Tapson
- Dept of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Hossein-Ardeschir Ghofrani
- Kerckhoff Clinic Bad Nauheim, University of Giessen, Bad Nauheim, Germany.,University of Giessen and Marburg Lung Centre (UGMLC), Justus-Liebig University Giessen and Member of the German Center for Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,These two authors contributed equally to this work
| | - David P Jenkins
- Royal Papworth Hospital, Cambridge, UK.,These two authors contributed equally to this work
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22
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A case report of breathlessness on exertion with an asymptomatic honeymoon period. Heart Lung 2018; 47:269-274. [DOI: 10.1016/j.hrtlng.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 02/04/2018] [Indexed: 11/17/2022]
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23
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Kempny A, Wort SJ, Dimopoulos K. Balloon pulmonary angioplasty for chronic thromboembolic disease: aiming for perfection. EUROINTERVENTION 2018; 13:1983-1986. [PMID: 29674298 DOI: 10.4244/eijv13i17a323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Aleksander Kempny
- Adult Congenital Heart Centre and National Centre for Pulmonary Hypertension, Royal Brompton Hospital, London, United Kingdom
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24
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Pitfalls in the Diagnosis of Acute Pulmonary Embolism on Computed Tomography: Common Pathologic and Imaging Mimics. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0273-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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How I use catheter-directed interventional therapy to treat patients with venous thromboembolism. Blood 2018; 131:733-740. [PMID: 29295847 DOI: 10.1182/blood-2016-11-693663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 12/19/2017] [Indexed: 12/18/2022] Open
Abstract
Patients who present with severe manifestations of acute venous thromboembolism (VTE) are at higher risk for premature death and long-term disability. In recent years, catheter-based interventional procedures have shown strong potential to improve clinical outcomes in selected VTE patients. However, physicians continue to be routinely faced with challenging decisions that pertain to the utilization of these risky and costly treatment strategies, and there is a relative paucity of published clinical trials with sufficient rigor and directness to inform clinical practice. In this article, using 3 distinct clinical scenario presentations, we draw from the available published literature describing the natural history, pathophysiology, treatments, and outcomes of VTE to illustrate the key factors that should influence clinical decision making for patients with severe manifestations of deep vein thrombosis and pulmonary embolism. The results of a recently completed pivotal multicenter randomized trial are also discussed.
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26
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Chronic Thromboembolic Pulmonary Hypertension. The Journey from a Curiosity to a Cure. Ann Am Thorac Soc 2018; 13 Suppl 3:S197-200. [PMID: 27571000 DOI: 10.1513/annalsats.201509-618as] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension is a progressive and life-threatening condition that is believed to be related to inadequate dissolution of acute pulmonary thromboemboli, followed by fibrotic organization. Without appropriate treatment, progressive pulmonary hypertension, right ventricular failure, and death may occur. While the disorder was initially described nearly a century ago in autopsy studies, antemortem diagnosis became feasible with the advent of cardiac catheterization and angiography techniques in the 1940s, while surgical thromboendarterectomy was not attempted until the 1960s. However, this procedure initially had high mortality rates until refinements in management and surgical techniques resulted in much improved outcomes starting in the 1980s. Many questions remain about the pathophysiology and epidemiology of this condition, with unclear contributions of genetics and environmental exposures. The optimal approach to diagnosis also continues to evolve, with improvements in preoperative imaging and hemodynamic assessment. Treatment of chronic thromboembolic pulmonary hypertension has not remained static, as surgical techniques continue to improve and newer pharmacological treatments and percutaneous catheter-based interventions may play therapeutic roles in selected patients. This is the introductory article of a series that provides a state-of-the-art review of chronic thromboembolic pulmonary hypertension.
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27
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Abstract
PURPOSE OF REVIEW Anesthesiologists are familiar with pulmonary emboli prophylaxis paradigms and many have witnessed acute intraoperative embolization. Clinicians must balance conservative anticoagulation and aggressive intervention in perioperative submassive pulmonary emboli, yet the bulk of the literature excludes surgery as a relative contraindication. This review will summarize the current treatment options for acute pulmonary emboli, drawing attention to special considerations in perioperative submassive pulmonary emboli, and discuss right ventricular monitoring to improve assessment of intervention efficacy. RECENT FINDINGS Recent reviews have identified the elevated risk and inadequacy of treatment of pulmonary embolism in intra and postoperative patients, in part because of the risks of systemic anticoagulation. Early studies of catheter-directed therapies have shown promising efficacy with a reduction in bleeding risk, which is especially important for perioperative patients. Success relies on defining endpoints, yet the practice of measuring mean pulmonary artery pressure alone to assess intervention efficacy is flawed. SUMMARY Identifying submassive pulmonary emboli that requires treatment and optimizing therapy remains difficult. Researchers must consider avoiding systemic anticoagulation and focus on designing trials that evaluate intervention efficacy in surgical patients. The success of catheter-directed therapy in early trials warrants further investigation into using these therapies in the treatment of perioperative submassive pulmonary emboli.
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28
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Sista AK, Kuo WT, Schiebler M, Madoff DC. Stratification, Imaging, and Management of Acute Massive and Submassive Pulmonary Embolism. Radiology 2017. [DOI: 10.1148/radiol.2017151978] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Akhilesh K. Sista
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - William T. Kuo
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - Mark Schiebler
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
| | - David C. Madoff
- From the Dept of Radiology, Div of Interventional Radiology, Weill Cornell Medical College, 525 E 68th St, New York, NY 10065 (A.K.S., D.C.M.); Dept of Radiology, Div of Interventional Radiology, Stanford Univ School of Medicine, Stanford, Calif (W.T.K.); and Dept of Radiology, Univ of Wisconsin School of Medicine, Madison, Wis (M.S.)
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Gall H, Hoeper MM, Richter MJ, Cacheris W, Hinzmann B, Mayer E. An epidemiological analysis of the burden of chronic thromboembolic pulmonary hypertension in the USA, Europe and Japan. Eur Respir Rev 2017; 26:26/143/160121. [PMID: 28356407 PMCID: PMC9488926 DOI: 10.1183/16000617.0121-2016] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/12/2017] [Indexed: 11/22/2022] Open
Abstract
Epidemiological data for chronic thromboembolic pulmonary hypertension (CTEPH) are limited and there are conflicting reports regarding its pathogenesis. A literature review was conducted to identify CTEPH epidemiological data up to June 2014. Data were analysed to provide estimates of the incidence of CTEPH in the USA, Europe and Japan. An epidemiological projection model derived country-specific estimates of future incidence and diagnosis rates of CTEPH. Overall, 25 publications and 14 databases provided quantitative epidemiological data. In the USA and Europe, the crude annual incidence of diagnosed pulmonary embolism and crude annual full (i.e. diagnosed and undiagnosed) incidence of CTEPH were 66–104 and 3–5 cases per 100 000 population, respectively, while in Japan these rates were lower at 6.7 and 1.9 per 100 000 population, respectively. In 2013, 7–29% of CTEPH cases in Europe and the USA were diagnosed, and the majority of patients were in New York Heart Association functional class III/IV at diagnosis. The projection model indicated that incidence of CTEPH will continue to increase over the next decade. These data suggest that CTEPH is underdiagnosed and undertreated, and there is an urgent need to increase awareness of CTEPH. High-quality epidemiological studies are required to increase understanding of CTEPH. Epidemiological data suggest that CTEPH is underdiagnosed and there is an urgent need to improve disease awarenesshttp://ow.ly/J0KC3095U2W
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Affiliation(s)
- Henning Gall
- Universities of Giessen and Marburg Lung Centre (UGMLC), member of the German Centre for Lung Research (DZL), Giessen, Germany
| | - Marius M Hoeper
- Clinic for Respiratory Medicine, Hannover Medical School, member of the German Centre for Lung Research (DZL), Hannover, Germany
| | - Manuel J Richter
- Universities of Giessen and Marburg Lung Centre (UGMLC), member of the German Centre for Lung Research (DZL), Giessen, Germany
| | | | | | - Eckhard Mayer
- Kerckhoff Heart and Lung Centre, Bad Nauheim, Germany
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Puis L, Vandezande E, Vercaemst L, Janssens P, Taverniers Y, Foulon M, Demeyere R, Delcroix M, Daenen W. Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Perfusion 2017; 20:101-8. [PMID: 15918447 DOI: 10.1191/0267659105pf791oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction. Pulmonary thromboendarterectomy (PTE) is a surgical procedure which is considered the only effective and potentially curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). CTEPH is a rare outcome from pulmonary emboli and, when left untreated, will result in right ventricular failure and death. Methods. From June 1999 to November 2003, 40 of these procedures were performed in our institution. Emphasis is placed on multidisciplinarity and cooperation between different medical and surgical disciplines. Perfusion management consists of myocar-dial and cerebral protection, deep hypothermia with multiple periods of circulatory arrest, reperfusion at hypothermia, hemofiltration and cellsaving techniques. Results. Hemodynamic improvement occurs immediately post operation. Mean pulmonary artery pressure decreased from 50±11 to 38±10 mmHg, pulmonary vascular resistance from 1246±482 to 515±294 dynes s/cm5 and cardiac index increased from 1.54±0.54 to 2.63±0.75 L/min per m2. Pump runs had an average duration of 187±29 min, circulatory arrest time was 29±11 min and crossclamp time 36±14 min. Extracorporeal membrane oxygenation can be an ultimate treatment for specific postoperative problems like persistent pulmonary hypertension and/or reperfusion pulmonary edema.
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Affiliation(s)
- Luc Puis
- Department of Extra Corporeal Circulation, UZ Gasthuisberg, KU Leuven, Belgium.
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31
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Park JS, Ahn J, Choi JH, Lee HW, Oh JH, Lee HC, Cha KS, Hong TJ. The predictive value of echocardiography for chronic thromboembolic pulmonary hypertension after acute pulmonary embolism in Korea. Korean J Intern Med 2017; 32:85-94. [PMID: 27044855 PMCID: PMC5214713 DOI: 10.3904/kjim.2014.175] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Revised: 12/08/2014] [Accepted: 03/23/2015] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication after acute pulmonary embolism (APE) and is associated with substantial morbidity and mortality. This study aimed to investigate the incidence of CTEPH after APE in Korea and to determine echocardiographic predictors of CTEPH. METHODS Among 381 patients with APE confirmed by chest computed tomography (CT) between January 2007 and July 2013, 246 consecutive patients with available echocardiographic data were enrolled in this study. CTEPH was defined as a persistent right ventricular systolic pressure (RVSP) greater than 35 mmHg on echocardiography during follow-up and persistent pulmonary embolism on the follow-up CT. RESULTS Fifteen patients (6.1%) had CTEPH. The rate of right ventricular (RV) dilatation (66.7% vs. 28.1%, p = 0.002) and the RVSP (75.5 mmHg vs. 39.0 mmHg, p < 0.001) were significantly higher in the CTEPH group. D-dimers, RV dilatation, RV hypertrophy, RVSP, and intermediate-risk APE were associated with the risk of CTEPH after APE (odds ratio [OR] 0.59, 5.11, 7.82, 1.06, and 4.86, respectively) on univariate analysis. RVSP remained as a significant predictor of CTEPH on multivariate analysis (OR, 1.056; 95% confidence interval, 1.006 to 1.109; p = 0.029). CONCLUSIONS This study showed that the incidence of CTEPH after APE in Korea was 6.1% and that initial RVSP by echocardiography was a strong prognostic factor for CTEPH.
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Affiliation(s)
| | | | - Jung Hyun Choi
- Correspondence to Jung Hyun Choi, M.D. Division of Cardiology, Medical Research Institute, Department of Internal Medicine, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7763 Fax: +82-51-240-7225 E-mail:
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Oka M, McMurtry IF, Oshima K. How does pulmonary endarterectomy cure CTEPH: A clue to cure PAH? Am J Physiol Lung Cell Mol Physiol 2016; 311:L766-L769. [PMID: 27591244 DOI: 10.1152/ajplung.00288.2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2016] [Accepted: 08/25/2016] [Indexed: 11/22/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a hot topic in the field of pulmonary hypertension, because many CTEPH patients are now curable by surgical pulmonary endarterectomy and more recently possibly by pulmonary balloon angioplasty. However, there are still uncertainties regarding the pathogenesis of CTEPH, specifically how and where the small vessel arteriopathy that is indistinguishable from that in pulmonary arterial hypertension (plexogenic arteriopathy) develops, and how pulmonary endarterectomy improves hemodynamics and possibly cures CTEPH. Based on our recent experimental finding that hemodynamic stress is fundamental for the development of plexogenic arteriopathy, we discuss the uncertainties of CTEPH and potential implication of the effectiveness of pulmonary endarterectomy for reversing plexogenic arteriopathy and possibly providing a novel approach to cure pulmonary arterial hypertension.
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Matthews DT, Hemnes AR. Current concepts in the pathogenesis of chronic thromboembolic pulmonary hypertension. Pulm Circ 2016; 6:145-54. [PMID: 27252839 DOI: 10.1086/686011] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by fibrotic obstruction of the proximal pulmonary arteries, and it is believed to result from incomplete thrombus resolution after acute pulmonary embolism. While treatment for this condition with surgery and medical therapy has improved outcomes, our understanding of the molecular mechanisms underlying CTEPH is incomplete. Numerous risk factors have been associated with the development of CTEPH, including but not limited to acquired thrombophilias and chronic inflammatory states. A minority of patients with CTEPH have an abnormal fibrin structure that may delay thrombus resolution. Recently, examination of resected scar material in patients with CTEPH has suggested that deficient angiogenesis may play a role in thrombus nonresolution, and there is increasing interest in factors that drive intravascular scar formation. An additional challenge in CTEPH research is understanding the etiology and implications of the small-vessel disease present in many patients. Future work will likely be directed at understanding the pathways important to disease pathogenesis through further examinations of resected tissue material, continued work on animal models, and genomic approaches to identify alterations in gene expression or gene variants that may distinguish CTEPH from other forms of pulmonary hypertension.
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Affiliation(s)
- Daniel T Matthews
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical School, Nashville, Tennessee, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical School, Nashville, Tennessee, USA
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Sista AK, Horowitz JM, Goldhaber SZ. Four key questions surrounding thrombolytic therapy for submassive pulmonary embolism. Vasc Med 2015; 21:47-52. [DOI: 10.1177/1358863x15614388] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Submassive pulmonary embolism (PE) remains a vexing entity, and the appropriate use of thrombolytic therapy for this subgroup continues to be actively debated. Catheter-directed thrombolysis has shown efficacy for submassive PE and is gaining momentum because of theoretically improved safety. This review poses and responds to four questions that explore the complex issues surrounding optimal therapy of submassive PE.
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Abstract
Critically ill patients with pulmonary hypertension (PH) often seem well, but they can decompensate dramatically in a short time. PH has several causes, classes, and complications; but the natural progression eventually leads to right ventricular failure, which can be extraordinarily difficult to manage. The purpose of this review is to discuss the causes, signs, and symptoms of PH as well as its management strategies and emergent complications. Treatment options are often limited, so it is imperative that the emergency department physician can recognize and manage these patients in a timely fashion.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Ground floor, Ravdin Hospital of the University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Ryan M Spangler
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Baltimore, MD 21201, USA
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a distinct subtype of pulmonary hypertension (PH). One disease hypothesis is that CTEPH results from the non-resolution of venous thromboembolism. CTEPH is characterised by the presence of obstructive fibrotic thromboembolic material in the major pulmonary vessels, with concomitant microvascular arteriopathy, resulting in progressive PH. The clinical presentation of CTEPH is similar to pulmonary arterial hypertension with nonspecific symptoms, but it is distinguished from pulmonary arterial hypertension by the presence of mismatched segmental defects on the ventilation/perfusion scan. The exact prevalence and incidence of CTEPH are unknown, but are thought to have been underestimated in the past. CTEPH is unique among the subgroups of PH in that it is potentially curable with pulmonary endarterectomy, a surgical intervention intended to remove the occlusive material from the pulmonary vasculature. However, in some patients the obstructions are technically inaccessible or the risk/benefit ratios are unfavourable, making the condition inoperable. It is thought that the involvement of the smaller, more distal vessels is a target for medical treatment. Untreated, CTEPH may result in right heart failure and death. The pathophysiological mechanisms which cause CTEPH are complex and have not yet been fully elucidated. CTEPH is distinct from other types of pulmonary hypertension, both in terms of its pathophysiology and treatmenthttp://ow.ly/L54ag
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Androulakis E, Lioudaki E, Christophides T, Ahmad M, Fayed H, Laskar N, Schreiber B. Chronic thromboembolic pulmonary arterial hypertension: a review of the literature and novel therapeutic approaches. Expert Rev Respir Med 2015; 9:351-9. [PMID: 25974147 DOI: 10.1586/17476348.2015.1046843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Chronic thromboembolic pulmonary hypertension is defined as pulmonary hypertension (PH) caused by single or recurrent pulmonary emboli and is characterized by chronic obstruction of the pulmonary arteries leading to increased vascular resistance and PH. Also, progressive remodeling may occur in occluded and nonoccluded territories. Better understanding of the underlying mechanisms and risk factors could improve diagnosis and allow appropriate interventions. Pulmonary endarterectomy is an established approach and is considered the definitive treatment for chronic PH, resulting from thromboembolic disease. Furthermore, percutaneous transluminal pulmonary angioplasty is technically feasible, especially for those with peripheral-type of the disease. In addition, several agents, including prostanoids, endothelin receptor antagonists and phosphodiesterase type-5 inhibitors, have been tested in selected patients yielding promising results. Several novel agents are under investigation, and extensive research is currently in progress aiming to resolve uncertainties in the understanding and treatment of the disease.
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Affiliation(s)
- Emmanuel Androulakis
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, London, UK
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Abstract
Magnetic resonance (MR) angiography of the pulmonary arteries is a rapidly evolving technique with proven clinical usefulness. Multiple-step protocols, such as MR perfusion followed by high-spatial resolution MR angiography, seem to be a good approach for the assessment of different vascular diseases affecting the pulmonary arteries. In combination with other imaging sequences, MR imaging is one of the most comprehensive potential noninvasive imaging techniques available.
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Affiliation(s)
- Sebastian Ley
- Diagnostic and Interventional Radiology, Chirurgische Klinik Dr Rinecker, Am Isarkanal 30, Munich 81379, Germany; Department of Clinical Radiology, Ludwig Maximilians University, Marchioninistrasse 15, Munich 81377, Germany.
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Affiliation(s)
- Irene Marthe Lang
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
| | - Michael Madani
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
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40
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Alias S, Lang IM. Coagulation and the vessel wall in pulmonary embolism. Pulm Circ 2014; 3:728-38. [PMID: 25006391 DOI: 10.1086/674768] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Accepted: 08/05/2013] [Indexed: 01/28/2023] Open
Abstract
Venous thromboembolism comprises deep-vein thrombosis, thrombus in transit, acute pulmonary embolism, and chronic thromboembolic pulmonary hypertension (CTEPH). Pulmonary thromboemboli commonly resolve, with restoration of normal pulmonary hemodynamics. When they fail to resorb, permanent occlusion of the deep veins and/or CTEPH are the consequences. Apart from endogenous fibrinolysis, venous thrombi resolve by a process of mechanical fragmentation, through organization of the thromboembolus by invasion of endothelial cells, leukocytes, and fibroblasts leading to recanalization. Recent data utilizing various models have contributed to a better understanding of venous thrombosis and the resolution process that is directed at maintaining vascular patency. This review summarizes the plasmatic and cellular components of venous thrombus formation and resolution.
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Affiliation(s)
- Sherin Alias
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Mercier O, Tivane A, Dorfmüller P, de Perrot M, Raoux F, Decante B, Eddahibi S, Dartevelle P, Fadel E. Piglet model of chronic pulmonary hypertension. Pulm Circ 2014; 3:908-15. [PMID: 25006407 DOI: 10.1086/674757] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 08/21/2013] [Indexed: 01/08/2023] Open
Abstract
None of the animal models have been able to reproduce all aspects of CTEPH because of the rapid resolution of the thrombi in the pulmonary vasculature. The aim of this study was to develop an easily reproducible large-animal model of chronic pulmonary hypertension (PH) related to the development of a postobstructive and overflow vasculopathy. Chronic PH was induced in 5 piglets by ligation of the left pulmonary artery (PA) through a midline sternotomy followed by weekly transcatheter embolization of the right lower-lobe arteries. Sham-operated piglets (n = 5) served as controls. Hemodynamics, RV function, lung morphometry, and endothelin-1 (ET-1) pathway gene expression (ET-1 and its receptors ETA and ETB) were assessed after 5 weeks in the obstructed (left lung and right lower lobe) and unobstructed (right upper lobe) territories. All animals developed chronic PH within 5 weeks. Compared to controls, chronic-PH animals had higher mean PA pressure (28.5 ± 1.7 vs. 11.6 ± 1.8 mmHg, P = 0.0001) and total pulmonary resistance (784 ± 160 vs. 378 ± 51 dyn s(-1) cm(-5), P = 0.05). Echocardiography showed RV enlargement, RV wall thickening (56 ± 5 vs. 30 ± 4 mm, P = 0.0003), decreased tricuspid annular plane systolic excursion (11.3 ± 0.9 vs. 14.4 ± 0.4 mm, P = 0.01), and paradoxical septal motion. In obstructed territories, morphometry demonstrated increases in the number of bronchial arteries per bronchus (8.7 ± 0.9 vs. 2 ± 0.17, P < 0.0001) and in distal PA media thickness (60% ± 2.8% vs. 29% ± 0.9%, P < 0.0001), consistent with postobstructive vasculopathy. Distal PA media thickness was increased in unobstructed territories (70% ± 2.4% vs. 29% ± 0.9%, P < 0.0001). ET-1 was overexpressed in unobstructed territories, compared to controls and obstructed territories. In conclusion, the large-animal model described here is reproducible and led to the development of PH in a relatively short time frame.
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Affiliation(s)
- Olaf Mercier
- Centre Chirurgical Marie Lannelongue, Paris-Sud University, Service de Chirurgie Thoracique, Vasculaire et de Transplantation cardio-pulmonaire, Le Plessis-Robinson, France ; Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Adriano Tivane
- Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Peter Dorfmüller
- Centre Chirurgical Marie Lannelongue, Paris-Sud University, Service de Chirurgie Thoracique, Vasculaire et de Transplantation cardio-pulmonaire, Le Plessis-Robinson, France ; Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Marc de Perrot
- Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - François Raoux
- Centre Chirurgical Marie Lannelongue, Paris-Sud University, Service de Chirurgie Thoracique, Vasculaire et de Transplantation cardio-pulmonaire, Le Plessis-Robinson, France
| | - Benoît Decante
- Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Saadia Eddahibi
- Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Philippe Dartevelle
- Centre Chirurgical Marie Lannelongue, Paris-Sud University, Service de Chirurgie Thoracique, Vasculaire et de Transplantation cardio-pulmonaire, Le Plessis-Robinson, France ; Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
| | - Elie Fadel
- Centre Chirurgical Marie Lannelongue, Paris-Sud University, Service de Chirurgie Thoracique, Vasculaire et de Transplantation cardio-pulmonaire, Le Plessis-Robinson, France ; Laboratoire de recherche chirurgicale and Institut National de la Santé et de la Recherche Médicale (INSERM) Unité 999, Le Plessis-Robinson, France
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Hoeper MM, Madani MM, Nakanishi N, Meyer B, Cebotari S, Rubin LJ. Chronic thromboembolic pulmonary hypertension. THE LANCET RESPIRATORY MEDICINE 2014; 2:573-82. [PMID: 24898750 DOI: 10.1016/s2213-2600(14)70089-x] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but debilitating and life-threatening complication of acute pulmonary embolism. CTEPH results from persistent obstruction of pulmonary arteries and progressive vascular remodelling. Not all patients presenting with CTEPH have a history of clinically overt pulmonary embolism. The diagnostic work-up to detect or rule out CTEPH should include ventilation-perfusion scintigraphy, which has high sensitivity and a negative predictive value of nearly 100%. CT angiography usually reveals typical features of CTEPH, including mosaic perfusion, part or complete occlusion of pulmonary arteries, and intraluminal bands and webs. Patients with suspected CTEPH should be referred to a specialist centre for right-heart catheterisation and pulmonary angiography. Surgical pulmonary endarterectomy remains the treatment of choice for CTEPH and is associated with excellent long-term results and a high probability of cure. For patients with inoperable CTEPH, various medical and interventional therapies are being developed.
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Affiliation(s)
- Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Centre for Lung Research (DZL), Hannover, Germany.
| | - Michael M Madani
- Department of Cardiothoracic Surgery, University of California, San Diego, CA, USA
| | - Norifumi Nakanishi
- Department of Cardiovascular Medicine, National Cardiovascular Centre, Osaka, Japan
| | - Bernhard Meyer
- Department of Radiology, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiovascular, Thoracic and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Lewis J Rubin
- Department of Respiratory Medicine, University of California, San Diego, CA, USA
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Alias S, Redwan B, Panzenboeck A, Winter MP, Schubert U, Voswinckel R, Frey MK, Jakowitsch J, Alimohammadi A, Hobohm L, Mangold A, Bergmeister H, Sibilia M, Wagner EF, Mayer E, Klepetko W, Hoelzenbein TJ, Preissner KT, Lang IM. Defective angiogenesis delays thrombus resolution: a potential pathogenetic mechanism underlying chronic thromboembolic pulmonary hypertension. Arterioscler Thromb Vasc Biol 2014; 34:810-819. [PMID: 24526692 DOI: 10.1161/atvbaha.113.302991] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Restoration of patency is a natural target of vascular remodeling after venous thrombosis that involves vascular endothelial cells and smooth muscle cells, as well as leukocytes. Acute pulmonary emboli usually resolve <6 months. However, in some instances, thrombi transform into fibrous vascular obstructions, resulting in occlusion of the deep veins, or in chronic thromboembolic pulmonary hypertension (CTEPH). We proposed that dysregulated thrombus angiogenesis may contribute to thrombus persistence. APPROACH AND RESULTS Mice with an endothelial cell-specific conditional deletion of vascular endothelial growth factor receptor 2/kinase insert domain protein receptor were used in a model of stagnant flow venous thrombosis closely resembling human deep vein thrombosis. Biochemical and functional analyses were performed on pulmonary endarterectomy specimens from patients with CTEPH, a human model of nonresolving venous thromboembolism. Endothelial cell-specific deletion of kinase insert domain protein receptor and subsequent ablation of thrombus vascularization delayed thrombus resolution. In accordance with these findings, organized human CTEPH thrombi were largely devoid of vascular structures. Several vessel-specific genes, such as kinase insert domain protein receptor, vascular endothelial cadherin, and podoplanin, were expressed at lower levels in white CTEPH thrombi than in organizing deep vein thrombi and organizing thrombi from aortic aneurysms. In addition, red CTEPH thrombi attenuated the angiogenic response induced by vascular endothelial growth factor. CONCLUSIONS In the present work, we propose a mechanism of thrombus nonresolution demonstrating that endothelial cell-specific deletion of kinase insert domain protein receptor abates thrombus vessel formation, misguiding thrombus resolution. Medical conditions associated with the development of CTEPH may be compromising early thrombus angiogenesis.
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Affiliation(s)
- Sherin Alias
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Bassam Redwan
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | | | - Max P Winter
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Uwe Schubert
- Institute for Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
| | - Robert Voswinckel
- Department of Lung Development and Remodeling, Max-Planck-Institute for Heart and Lung Research, Bad Nauheim, Germany
| | - Maria K Frey
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | | | - Lukas Hobohm
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Andreas Mangold
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Helga Bergmeister
- Department of Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - Maria Sibilia
- Institute for Cancer Research, Department of Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Erwin F Wagner
- Centro Nacional de Investigaciones Oncológicas, Madrid, Spain
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Clinic Heart and Lung Centre, Bad Nauheim, Germany
| | - Walter Klepetko
- Department of Cardiothoracic Surgery, Medical University of Vienna, Vienna, Austria
| | - Thomas J Hoelzenbein
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Salzburg, Austria
| | - Klaus T Preissner
- Institute for Biochemistry, Medical School, Justus-Liebig-University, Giessen, Germany
| | - Irene M Lang
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
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Confalonieri M, Kodric M, Longo C, Vassallo FG. Bosentan for chronic thromboembolic pulmonary hypertension. Expert Rev Cardiovasc Ther 2014; 7:1503-12. [DOI: 10.1586/erc.09.148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Veit F, Pak O, Egemnazarov B, Roth M, Kosanovic D, Seimetz M, Sommer N, Ghofrani HA, Seeger W, Grimminger F, Brandes RP, Schermuly RT, Weissmann N. Function of NADPH oxidase 1 in pulmonary arterial smooth muscle cells after monocrotaline-induced pulmonary vascular remodeling. Antioxid Redox Signal 2013; 19:2213-31. [PMID: 23706097 DOI: 10.1089/ars.2012.4904] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
AIMS Chronic hypoxia induces pulmonary hypertension (PH) that is concomitant with pulmonary vascular remodeling. Reactive oxygen species (ROS) are thought to play a major role in this. Recent findings suggest that ROS production by NADPH oxidase 4 (Nox4) is important in this remodeling. We investigated whether ROS production by Nox is also important in an inflammatory model of monocrotaline (MCT)-induced PH. We examined ROS production, their possible sources, and their impact on the function of pulmonary arterial smooth muscle cells (PASMC) isolated from MCT-treated and healthy rats. RESULTS MCT-PASMC showed increased intracellular superoxide production, migration, and proliferation compared with healthy controls due to increased Nox1 expression. A comparison of PASMC from MCT- and nontreated rats revealed an up-regulation of Sod2, Nrf2, cyclin D1, and matrix metalloproteinase-9 (MMP-9) as well as an increased phosphorylation of cofilin and extracellular signal-regulated kinases (Erk). Expression of Sod2, Nrf2, and cyclin D1 and phosphorylation of cofilin and Erk were Nox1 dependent. INNOVATION The role of ROS in PH is not fully understood. Mitochondria and Nox have been suggested as sources of altered ROS generation in PH, yet it remains unclear whether increased or decreased ROS contributes to the development of PH. Our studies provide evidence that for different triggers of PH, different Nox isoforms regulate proliferation and migration of PASMC. CONCLUSION In contrast to hypoxia-induced PH, Nox1 but not Nox4 is responsible for pathophysiological proliferation and migration of PASMC in an inflammatory model of MCT-induced PH via increased superoxide production. Thus, different Nox isoforms may be targeted in different forms of PH.
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Affiliation(s)
- Florian Veit
- 1 Excellencecluster Cardio-Pulmonary System (ECCPS), German Lung Center (DZL), Universities of Giessen and Marburg Lung Center (UGMLC), Justus-Liebig-University Giessen , Giessen, Germany
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Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
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Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
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Page A, Ali JM, Maraka J, Mackenzie-Ross R, Jenkins DP. Management of chronic thromboembolic pulmonary hypertension: current status and emerging options. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.13.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Maliyasena VA, Hopkins PMA, Thomson BM, Dunning J, Wall DA, Ng BJ, McNeil KD, Mullany D, Kermeen FD. An Australian tertiary referral center experience of the management of chronic thromboembolic pulmonary hypertension. Pulm Circ 2012; 2:359-64. [PMID: 23130104 PMCID: PMC3487304 DOI: 10.4103/2045-8932.101649] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The objective of this study was to report the outcome of pulmonary endarterectomy (PEA) surgery performed for chronic thromboembolic pulmonary hypertension (CTEPH) at a single tertiary center. The prospective study consisted of 35 patients with surgically amenable CTEPH undergoing PEA between September 2004 and September 2010. The main outcome measures were Functional (New York Heart Association [NYHA] class, 6-Minute Walk Distance), hemodynamic (echocardiography, right heart catheterization, and cardiac MRI), and outcome data (morbidity and mortality). Following PEA, there were significant improvements in NYHA class (pre 2.9±0.7 vs. post 1.3±0.5, P < 0.0001), right ventricular systolic pressure (pre 77.4±24.8 mmHg vs. post 45.1±24.9 mmHg, P = 0.0005), 6-Minute Walk Distance (pre 419.6±109.4 m vs. post 521.6±83.5 m, P = 0.0017), mean pulmonary artery pressure (pre 41.8±15.3 mmHg vs. post 24.7±8.8 mmHg, P = 0.0006), and cardiac MRI indices (end diastolic volume pre 213.8±49.2 mL vs. post 148.1±34.5 mL, P < 0.0001; ejection fraction pre 40.7±9.8 mL vs. post 48.1±8.9 mL, P = 0.0069). The mean cardiopulmonary bypass time was 258.77±26.16 min, with a mean circulatory arrest time of 43.83±28.78 min, a mean ventilation time of 4.7±7.93 days (range 0.2-32.7), and a mean intensive care unit stay of 7.22±8.71 days (range 1.1-33.8). Complications included reperfusion lung injury (20%), persistent pulmonary hypertension (17.1%), slow respiratory wean (25.7%), pericardial effusion (11.4%), and cardiac tamponade (5.7%). 1-year mortality post-procedure was 11.4%. Pulmonary endarterectomy can be performed safely with relatively low mortality.
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Affiliation(s)
- Videshinie A Maliyasena
- Queensland Centre for Pulmonary Transplantation and Vascular Diseases, The Prince Charles Hospital, Brisbane, Australia
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Echocardiographic evaluation for pulmonary hypertension after recurrent pulmonary embolism. Thromb Res 2011; 128:e144-7. [DOI: 10.1016/j.thromres.2011.07.045] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Revised: 07/21/2011] [Accepted: 07/22/2011] [Indexed: 11/21/2022]
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Pepke-Zaba J, Delcroix M, Lang I, Mayer E, Jansa P, Ambroz D, Treacy C, D'Armini AM, Morsolini M, Snijder R, Bresser P, Torbicki A, Kristensen B, Lewczuk J, Simkova I, Barberà JA, de Perrot M, Hoeper MM, Gaine S, Speich R, Gomez-Sanchez MA, Kovacs G, Hamid AM, Jaïs X, Simonneau G. Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Circulation 2011; 124:1973-81. [DOI: 10.1161/circulationaha.110.015008] [Citation(s) in RCA: 652] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Chronic thromboembolic pulmonary hypertension (CTEPH) is often a sequel of venous thromboembolism with fatal natural history; however, many cases can be cured by pulmonary endarterectomy. The clinical characteristics and current management of patients enrolled in an international CTEPH registry was investigated.
Methods and Results—
The international registry included 679 newly diagnosed (≤6 months) consecutive patients with CTEPH, from February 2007 until January 2009. Diagnosis was confirmed by right heart catheterization, ventilation-perfusion lung scintigraphy, computerized tomography, and/or pulmonary angiography. At diagnosis, a median of 14.1 months had passed since first symptoms; 427 patients (62.9%) were considered operable, 247 (36.4%) nonoperable, and 5 (0.7%) had no operability data; 386 patients (56.8%, ranging from 12.0%– 60.9% across countries) underwent surgery. Operable patients did not differ from nonoperable patients relative to symptoms, New York Heart Association class, and hemodynamics. A history of acute pulmonary embolism was reported for 74.8% of patients (77.5% operable, 70.0% nonoperable). Associated conditions included thrombophilic disorder in 31.9% (37.1% operable, 23.5% nonoperable) and splenectomy in 3.4% of patients (1.9% operable, 5.7% nonoperable). At the time of CTEPH diagnosis, 37.7% of patients initiated at least 1 pulmonary arterial hypertension–targeted therapy (28.3% operable, 53.8% nonoperable). Pulmonary endarterectomy was performed with a 4.7% documented mortality rate.
Conclusions—
Despite similarities in clinical presentation, operable and nonoperable CTEPH patients may have distinct associated medical conditions. Operability rates vary considerably across countries, and a substantial number of patients (operable and nonoperable) receive off-label pulmonary arterial hypertension–targeted treatments.
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Affiliation(s)
- Joanna Pepke-Zaba
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Marion Delcroix
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Irene Lang
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Eckhard Mayer
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Pavel Jansa
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - David Ambroz
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Carmen Treacy
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Andrea M. D'Armini
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Marco Morsolini
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Repke Snijder
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Paul Bresser
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Adam Torbicki
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Bent Kristensen
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Jerzy Lewczuk
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Iveta Simkova
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Joan A. Barberà
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Marc de Perrot
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Marius M. Hoeper
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Sean Gaine
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Rudolf Speich
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Miguel A. Gomez-Sanchez
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Gabor Kovacs
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Abdul Monem Hamid
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Xavier Jaïs
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
| | - Gérald Simonneau
- From the Papworth Hospital, Cambridge, United Kingdom (J.P.-Z., C.T.); University Hospital Gasthuisberg, Leuven, Belgium (M.D.); Medical University of Vienna, Vienna, Austria (I.L.); Kerckhoff Heart and Lung Center, Bad Nauheim, Germany (E.M.); Clinical Department of Cardiology and Angiology of the First Faculty of Medicine and General Teaching Hospital, Prague, Czech Republic (P.J., D.A.); San Matteo Hospital, University of Pavia, Pavia, Italy (A.M.D., M.M.); St. Antonius Ziekenhuis, Nieuwegein,
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