1
|
Harder EM, Abtin F, Nardelli P, Brownstein A, Channick RN, Washko GR, Goldin J, San José Estépar R, Rahaghi FN, Saggar R. Pulmonary Hypertension in Idiopathic Interstitial Pneumonia Is Associated with Small Vessel Pruning. Am J Respir Crit Care Med 2024; 209:1170-1173. [PMID: 38502314 DOI: 10.1164/rccm.202312-2343le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 03/14/2024] [Indexed: 03/21/2024] Open
Affiliation(s)
- Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | - Pietro Nardelli
- Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts; and
| | - Adam Brownstein
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - Richard N Channick
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | | | | | - Farbod N Rahaghi
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, and
| | - Rajan Saggar
- Division of Pulmonary, Critical Care, Sleep Medicine, Clinical Immunology and Allergy, David Geffen School of Medicine at UCLA, University of California Los Angeles, Los Angeles, California
| |
Collapse
|
2
|
Mocumbi A, Humbert M, Saxena A, Jing ZC, Sliwa K, Thienemann F, Archer SL, Stewart S. Pulmonary hypertension. Nat Rev Dis Primers 2024; 10:1. [PMID: 38177157 DOI: 10.1038/s41572-023-00486-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 01/06/2024]
Abstract
Pulmonary hypertension encompasses a range of conditions directly or indirectly leading to elevated pressures within the pulmonary arteries. Five main groups of pulmonary hypertension are recognized, all defined by a mean pulmonary artery pressure of >20 mmHg: pulmonary arterial hypertension (rare), pulmonary hypertension associated with left-sided heart disease (very common), pulmonary hypertension associated with lung disease (common), pulmonary hypertension associated with pulmonary artery obstructions, usually related to thromboembolic disease (rare), and pulmonary hypertension with unclear and/or multifactorial mechanisms (rare). At least 1% of the world's population is affected, with a greater burden more likely in low-income and middle-income countries. Across all its forms, pulmonary hypertension is associated with adverse vascular remodelling with obstruction, stiffening and vasoconstriction of the pulmonary vasculature. Without proactive management this leads to hypertrophy and ultimately failure of the right ventricle, the main cause of death. In older individuals, dyspnoea is the most common symptom. Stepwise investigation precedes definitive diagnosis with right heart catheterization. Medical and surgical treatments are approved for pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. There are emerging treatments for other forms of pulmonary hypertension; but current therapy primarily targets the underlying cause. There are still major gaps in basic, clinical and translational knowledge; thus, further research, with a focus on vulnerable populations, is needed to better characterize, detect and effectively treat all forms of pulmonary hypertension.
Collapse
Affiliation(s)
- Ana Mocumbi
- Faculdade de Medicina, Universidade Eduardo Mondlane, Maputo, Moçambique.
- Instituto Nacional de Saúde, EN 1, Marracuene, Moçambique.
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre (Assistance Publique Hôpitaux de Paris), Université Paris-Saclay, INSERM UMR_S 999, Paris, France
- ERN-LUNG, Le Kremlin Bicêtre, Paris, France
| | - Anita Saxena
- Sharma University of Health Sciences, Haryana, New Delhi, India
| | - Zhi-Cheng Jing
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, China
| | - Karen Sliwa
- Cape Heart Institute, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
| | - Friedrich Thienemann
- Department of Medicine, Groote Schuur Hospital, Faculty of Health Science, University of Cape Town, Cape Town, South Africa
- Department of Internal Medicine, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Stephen L Archer
- Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Simon Stewart
- Institute of Health Research, University of Notre Dame, Fremantle, Western Australia, Australia
| |
Collapse
|
3
|
Condliffe R, Durrington C, Hameed A, Lewis RA, Venkateswaran R, Gopalan D, Dorfmüller P. Clinical-radiological-pathological correlation in pulmonary arterial hypertension. Eur Respir Rev 2023; 32:230138. [PMID: 38123231 PMCID: PMC10731450 DOI: 10.1183/16000617.0138-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/21/2023] [Indexed: 12/23/2023] Open
Abstract
Pulmonary hypertension (PH) is defined by the presence of a mean pulmonary arterial pressure >20 mmHg. Current guidelines describe five groups of PH with shared pathophysiological and clinical features. In this paper, the first of a series covering all five PH classification groups, the clinical, radiological and pathological features of pulmonary arterial hypertension (PAH) will be reviewed. PAH may develop in the presence of associated medical conditions or a family history, following exposure to certain medications or drugs, or may be idiopathic in nature. Although all forms of PAH share common histopathological features, the presence of certain pulmonary arterial abnormalities, such as plexiform lesions, and extent of co-existing pulmonary venous involvement differs between the different subgroups. Radiological investigations are key to diagnosing the correct form of PH and a systematic approach to interpretation, especially of computed tomography, is essential.
Collapse
Affiliation(s)
- Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- These authors contributed equally to this work
| | - Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Department of Infection, Immunity and Cardiovascular Disease, Medical School, University of Sheffield, Sheffield, UK
| | - Robert A Lewis
- Department of Respiratory Medicine, Middlemore Hospital, Auckland, New Zealand
| | - Rajamiyer Venkateswaran
- Department of Heart and Lung Transplantation, Manchester University NHS Foundation Trust, Manchester, UK
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
- These authors contributed equally to this work
| | - Peter Dorfmüller
- Department of Pathology, University Hospital of Giessen and Marburg, Giessen, Germany
- Institute for Lung Health, Giessen, Germany
- These authors contributed equally to this work
| |
Collapse
|
4
|
Zhao W, Guo J, Dong N, Hei H, Duan X, Shen C. Diagnostic value of 3D volume measurement of central pulmonary artery based on CTPA images in the pulmonary hypertension. BMC Med Imaging 2023; 23:211. [PMID: 38093192 PMCID: PMC10720078 DOI: 10.1186/s12880-023-01180-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND This retrospective study aims to evaluate the diagnostic value of volume measurement of central pulmonary arteries using computer tomography pulmonary angiography (CTPA) for predicting pulmonary hypertension (PH). METHODS A total of 59 patients in our hospital from November 2013 to April 2021 who underwent both right cardiac catheterization (RHC) and CTPA examination were included. Systolic pulmonary artery pressure (SPAP), mean PAP (mPAP), and diastolic PAP (DPAP) were acquired from RHC testing. Patients were divided into the non-PH group (18 cases) and the PH group (41 cases). The diameters of the main pulmonary artery (DMPA), right pulmonary artery (DRPA), and left pulmonary artery (DLPA) were measured manually. A 3D model software was used for the segmentation of central pulmonary arteries. The cross-sectional areas (AMPA, ARPA, ALPA) and the volumes (VMPA, VRPA, VLPA) were calculated. Measurements of the pulmonary arteries derived from CTPA images were compared between the two groups, and correlated with the parameters of RHC testing. ROC curves and decision curve analysis (DCA) were used to evaluate the benefit of the three-dimensional CTPA parameters for predicting PH. A multiple linear regression model with a forward-step approach was adopted to integrate all statistically significant CTPA parameters for PH prediction. RESULTS All parameters (DMPA, DRPA, DLPA, AMPA, ARPA, ALPA, VMPA, VRPA, and VLPA) of CTPA images exhibited significantly elevated in the PH group in contrast to the non-PH group (P < 0.05), and showed positive correlations with the parameters of RHC testing (mPAP, DPAP, SPAP) (r ranged 0.586~0.752 for MPA, 0.527~0.640 for RPA, and 0.302~0.495 for LPA, all with P < 0.05). For the MPA and RPA, 3D parameters showed higher correlation coefficients compared to their one-dimensional and two-dimensional counterparts. The ROC analysis indicated that the VMPA showed higher area under the curves (AUC) than the DMPA and AMPA without significance, and the VRPA showed higher AUC than the DRPA and ARPA significantly (DRPA vs. VRPA, Z = 2.029, P = 0.042; ARPA vs. VRPA, Z = 2.119, P = 0.034). The DCA demonstrated that the three-dimensional parameters could provide great net benefit for MPA and RPA. The predictive equations for mPAP, DPAP, and SPAP were formulated as [8.178 + 0.0006 * VMPA], [1.418 + 0.0005 * VMPA], and [-11.137 + 0.0006*VRPA + 1.259 * DMPA], respectively. CONCLUSION The 3D volume measurement of the MPA and RPA based on CTPA images maybe more informative than the traditional diameter and cross-sectional area in predicting PH.
Collapse
Affiliation(s)
- Wanwan Zhao
- Department of PET/CT, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, 710061, China
- Department of Imaging, Nuclear Industry 215 Hospital of Shaanxi Province, Xianyang, Shaanxi, 712200, China
| | - Jialing Guo
- Department of Ultrasound, Jingbian People's Hospital, Yulin, Shaanxi, 718500, China
| | - Ningli Dong
- Department of Imaging, The Second Hospital of Traditional Chinese Medicine of Baoji, Baoji, Shaanxi, 721300, China
| | - Huanhuan Hei
- Department of Imaging, The Second Hospital of Xi'an Medical College, Xi'an, Shaanxi, 710038, China
| | - Xiaoyi Duan
- Department of PET/CT, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, 710061, China
| | - Cong Shen
- Department of PET/CT, The First Affiliated Hospital of Xi'an Jiaotong University, 277 Yanta West Road, Xi'an, Shaanxi, 710061, China.
| |
Collapse
|
5
|
Caccamo M, Harrell FE, Hemnes AR. Evolution and optimization of clinical trial endpoints and design in pulmonary arterial hypertension. Pulm Circ 2023; 13:e12271. [PMID: 37554146 PMCID: PMC10405062 DOI: 10.1002/pul2.12271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/20/2023] [Accepted: 07/25/2023] [Indexed: 08/10/2023] Open
Abstract
Selection of endpoints for clinical trials in pulmonary arterial hypertension (PAH) is challenging because of the small numbers of patients and the changing expectations of patients, clinicians, and regulators in this evolving therapy area. The most commonly used primary endpoint in PAH trials has been 6-min walk distance (6MWD), leading to the approval of several targeted therapies. However, single surrogate endpoints such as 6MWD or hemodynamic parameters may not correlate with clinical outcomes. Composite endpoints of clinical worsening have been developed to reflect patients' overall condition more accurately, although there is no standard definition of worsening. Recently there has been a shift to composite endpoints assessing clinical improvement, and risk scores developed from registry data are increasingly being used. Biomarkers are another area of interest, although brain natriuretic peptide and its N-terminal prohormone are the only markers used for risk assessment or as endpoints in PAH. A range of other genetic, metabolic, and immunologic markers is currently under investigation, along with conventional and novel imaging modalities. Patient-reported outcomes are an increasingly important part of evaluating new therapies, and several PAH-specific tools are now available. In the future, alternative statistical techniques and trial designs, such as patient enrichment strategies, will play a role in evaluating PAH-targeted therapies. In addition, modern sequencing techniques, imaging analyses, and high-dimensional statistical modeling/machine learning may reveal novel markers that can play a role in the diagnosis and monitoring of PAH.
Collapse
Affiliation(s)
- Marco Caccamo
- Division of CardiologyWVU Heart and Vascular InstituteMorgantownWest VirginiaUSA
| | - Frank E. Harrell
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Anna R. Hemnes
- Division of Allergy, Pulmonary, and Critical Care MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| |
Collapse
|
6
|
Zhao Q, Zhang R, Shi J, Xie H, Zhang L, Li F, Jiang R, Wu W, Luo C, Qiu H, Li H, He J, Yuan P, Liu J, Gong S, Wang L. Imaging Features in BMPR2 Mutation-associated Pulmonary Arterial Hypertension. Radiology 2023; 307:e222488. [PMID: 37191488 DOI: 10.1148/radiol.222488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Background Germline mutation in the BMPR2 gene is common in patients with pulmonary arterial hypertension (PAH). However, its association with imaging findings in these patients is, to the knowledge of the authors, unknown. Purpose To characterize distinctive pulmonary vascular abnormalities at CT and pulmonary artery angiography in patients with and without BMPR2 mutation. Materials and Methods In this retrospective study, chest CT scans, pulmonary artery angiograms, and genetic test data were acquired for patients diagnosed with idiopathic PAH (IPAH) or heritable PAH (HPAH) between January 2010 and December 2021. Perivascular halo, neovascularity, centrilobular ground-glass opacity (GGO), and panlobular GGO were evaluated at CT and graded on a four-point severity scale by four independent readers. Clinical characteristics and imaging features between patients with BMPR2 mutation and noncarriers were analyzed using the Kendall rank-order coefficient and the Kruskal-Wallis test. Results This study included 82 patients with BMPR2 mutation (mean age, 38 years ± 15 [SD]; 34 men; 72 patients with IPAH and 10 patients with HPAH) and 193 patients without the mutation, all with IPAH (mean age, 41 years ± 15; 53 men). A total of 115 patients (42%; 115 of 275) had neovascularity, and 56 patients (20%; 56 of 275) had perivascular halo at CT, and so-called frost crystals were observed on pulmonary artery angiograms in 14 of 53 (26%) patients. Compared with patients without BMPR2 mutation, patients with BMPR2 mutation more frequently showed two distinctive radiographic manifestations, perivascular halo and neovascularity (38% [31 of 82] vs 13% [25 of 193] in perivascular halo [P < .001] and 60% [49 of 82] vs 34% [66 of 193] in neovascularity [P < .001], respectively). "Frost crystals" were more frequent in patients with BMPR2 mutation compared with noncarriers (53% [10 of 19] vs 12% [four of 34]; P < .01). Severe perivascular halo frequently coexisted with severe neovascularity in patients with BMPR2 mutation. Conclusion Patients with PAH with BMPR2 mutation showed distinctive features at CT, specifically perivascular halo and neovascularity. This suggested a link between the genetic, pulmonary, and systemic manifestations that underly the pathogenesis of PAH. © RSNA, 2023 Supplemental material is available for this article.
Collapse
Affiliation(s)
- Qinhua Zhao
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Rui Zhang
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Jingyun Shi
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Huikang Xie
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Liping Zhang
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Fei Li
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Rong Jiang
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Wenhui Wu
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Cijun Luo
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Hongling Qiu
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Huiting Li
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Jing He
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Ping Yuan
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - JinMing Liu
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Sugang Gong
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| | - Lan Wang
- From the Departments of Pulmonary Circulation (Q.Z., R.Z., R.J., W.W., C.L., H.Q., H.L., J.H., P.Y., J.L., S.G., L.W.), Radiology (J.S., F.L.), and Pathology (H.X., L.Z.), Shanghai Pulmonary Hospital, Tongji University School of Medicine, No. 507 Zhengmin Rd, Shanghai 200433, China
| |
Collapse
|
7
|
Yokose M, Tomoe T, Yamaguchi T, Yasu T. An autopsy case of pulmonary arterial hypertension in an elderly patient with multimorbidity: a case report. Eur Heart J Case Rep 2022; 6:ytab527. [PMID: 35028503 PMCID: PMC8753136 DOI: 10.1093/ehjcr/ytab527] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/26/2021] [Accepted: 12/22/2021] [Indexed: 11/12/2022]
Abstract
Abstract
Background
There is an increasing number of elderly patients with pulmonary arterial hypertension (PAH), and their characteristics differ from those of young or middle-aged patients with this condition.
Case summary
A 73-year-old woman with a history of myocardial infarction and cardiovascular risk factors was admitted to the hospital with 2-week exertional dyspnoea. Her initial diagnosis was heart failure with preserved ejection fraction, but the symptoms persisted despite receiving treatment with diuretics. Additional tests showed a significant decrease in diffusing capacity of carbon monoxide and findings suggestive of severe pulmonary hypertension (PH). Contrast-enhanced computed tomography of the chest, and pulmonary angiography, showed no narrowing or obstruction of the pulmonary arteries. Right heart catheterization revealed haemodynamic data implying pre-capillary PH. Her condition gradually deteriorated to World Health Organization functional class IV, and sequential combination therapy with tadalafil, macitentan, and selexipag was initiated with a PAH diagnosis; however, she died 1 month later. Pathological findings in autopsy were consistent with PAH, and some parts of the lungs revealed the presence of obstructive and interstitial lung disease.
Discussion
The majority of elderly patients with PAH might have multimorbidity. However, there is no specific treatment strategy. It is associated with diagnostic delay and worse prognosis; therefore, early suspicion and comprehensive tests, including right heart catheterization, are essential for better management.
Collapse
Affiliation(s)
- Masashi Yokose
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takashi Tomoe
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takehiko Yamaguchi
- Department of Pathology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| | - Takanori Yasu
- Department of Cardiovascular Medicine and Nephrology, Dokkyo Medical University Nikko Medical Center, 632 Takatoku, Nikko, Tochigi 321-2593, Japan
| |
Collapse
|
8
|
Dwivedi K, Condliffe R, Sharkey M, Lewis R, Alabed S, Rajaram S, Hill C, Saunders L, Metherall P, Alandejani F, Alkhanfar D, Wild JM, Lu H, Kiely DG, Swift AJ. Computed tomography lung parenchymal descriptions in routine radiological reporting have diagnostic and prognostic utility in patients with idiopathic pulmonary arterial hypertension and pulmonary hypertension associated with lung disease. ERJ Open Res 2022; 8:00549-2021. [PMID: 35083317 PMCID: PMC8784758 DOI: 10.1183/23120541.00549-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Patients with pulmonary hypertension (PH) and lung disease may pose a diagnostic dilemma between idiopathic pulmonary arterial hypertension (IPAH) and PH associated with lung disease (PH-CLD). The prognostic impact of common computed tomography (CT) parenchymal features is unknown. METHODS 660 IPAH and PH-CLD patients assessed between 2001 and 2019 were included. Reports for all CT scans 1 year prior to diagnosis were analysed for common lung parenchymal patterns. Cox regression and Kaplan-Meier analysis were performed. RESULTS At univariate analysis of the whole cohort, centrilobular ground-glass (CGG) changes (hazard ratio, HR 0.29) and ground-glass opacification (HR 0.53) predicted improved survival, while honeycombing (HR 2.79), emphysema (HR 2.09) and fibrosis (HR 2.38) predicted worse survival (all p<0.001). Fibrosis was an independent predictor after adjusting for baseline demographics, PH severity and diffusing capacity of the lung for carbon monoxide (HR 1.37, p<0.05). Patients with a clinical diagnosis of IPAH who had an absence of reported parenchymal lung disease (IPAH-noLD) demonstrated superior survival to patients diagnosed with either IPAH who had coexistent CT lung disease or PH-CLD (2-year survival of 85%, 60% and 46%, respectively, p<0.05). CGG changes were present in 23.3% of IPAH-noLD and 5.8% of PH-CLD patients. There was no significant difference in survival between IPAH-noLD patients with or without CGG changes. PH-CLD patients with fibrosis had worse survival than those with emphysema. INTERPRETATION Routine clinical reports of CT lung parenchymal disease identify groups of patients with IPAH and PH-CLD with significantly different prognoses. Isolated CGG changes are not uncommon in IPAH but are not associated with worse survival.
Collapse
Affiliation(s)
- Krit Dwivedi
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK.,Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,Co-first authors
| | - Robin Condliffe
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospitals, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,Co-first authors
| | - Michael Sharkey
- Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,3DLab, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Robert Lewis
- Pulmonary Vascular Disease Unit, Royal Hallamshire Hospitals, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Samer Alabed
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK.,Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Smitha Rajaram
- Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Catherine Hill
- Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Laura Saunders
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK
| | - Peter Metherall
- Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,3DLab, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Faisal Alandejani
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK
| | - Dheyaa Alkhanfar
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK
| | - Jim M Wild
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK
| | - Haiping Lu
- Dept of Computer Science, University of Sheffield, Sheffield, UK
| | - David G Kiely
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK.,Pulmonary Vascular Disease Unit, Royal Hallamshire Hospitals, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,Co-senior authors
| | - Andrew J Swift
- Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Medical School, Sheffield, UK.,Dept of Radiology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,3DLab, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK.,Co-senior authors
| |
Collapse
|
9
|
Rahaghi FN, Trieu M, Shaikh F, Abtin F, Diaz AA, Liang LL, Barjaktarevic I, Channick RN, San José Estépar R, Washko GR, Saggar R. Evolution of Obstructive Lung Function in Advanced Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2021; 204:1478-1481. [PMID: 34555310 PMCID: PMC8865712 DOI: 10.1164/rccm.202105-1169le] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Farbod N. Rahaghi
- Brigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusetts
| | - Megan Trieu
- University of California, Los AngelesLos Angeles, California
| | - Faisal Shaikh
- University of California, Los AngelesLos Angeles, California
| | - Fereidoun Abtin
- University of California, Los AngelesLos Angeles, California
| | - Alejandro A. Diaz
- Brigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusetts
| | - Lloyd L. Liang
- University of California, Los AngelesLos Angeles, California
| | | | | | | | - George R. Washko
- Brigham and Women's Hospital and Harvard Medical SchoolBoston, Massachusetts
| | - Rajan Saggar
- University of California, Los AngelesLos Angeles, California
| |
Collapse
|
10
|
Visualizing Pulmonary Vascular Disease With CT Scanning. Chest 2021; 160:1998-1999. [PMID: 34872662 DOI: 10.1016/j.chest.2021.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 08/04/2021] [Indexed: 11/20/2022] Open
|
11
|
Prediction of chronic thromboembolic pulmonary hypertension with standardised evaluation of initial computed tomography pulmonary angiography performed for suspected acute pulmonary embolism. Eur Radiol 2021; 32:2178-2187. [PMID: 34854928 PMCID: PMC8921171 DOI: 10.1007/s00330-021-08364-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 09/05/2021] [Accepted: 09/27/2021] [Indexed: 11/21/2022]
Abstract
Objectives Closer reading of computed tomography pulmonary angiography (CTPA) scans of patients presenting with acute pulmonary embolism (PE) may identify those at high risk of developing chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to validate the predictive value of six radiological predictors that were previously proposed. Methods Three hundred forty-one patients with acute PE were prospectively followed for development of CTEPH in six European hospitals. Index CTPAs were analysed post hoc by expert chest radiologists blinded to the final diagnosis. The accuracy of the predictors using a predefined threshold for ‘high risk’ (≥ 3 predictors) and the expert overall judgment on the presence of CTEPH were assessed. Results CTEPH was confirmed in nine patients (2.6%) during 2-year follow-up. Any sign of chronic thrombi was already present in 74/341 patients (22%) on the index CTPA, which was associated with CTEPH (OR 7.8, 95%CI 1.9–32); 37 patients (11%) had ≥ 3 of 6 radiological predictors, of whom 4 (11%) were diagnosed with CTEPH (sensitivity 44%, 95%CI 14–79; specificity 90%, 95%CI 86–93). Expert judgment raised suspicion of CTEPH in 27 patients, which was confirmed in 8 (30%; sensitivity 89%, 95%CI 52–100; specificity 94%, 95%CI 91–97). Conclusions The presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future CTEPH diagnosis, comparable to overall expert judgment, while the latter was associated with higher sensitivity. Dedicated CTPA reading for signs of CTEPH may therefore help in early detection of CTEPH after PE, although in our cohort this strategy would not have detected all cases. Key Points • Three expert chest radiologists re-assessed CTPA scans performed at the moment of acute pulmonary embolism diagnosis and observed a high prevalence of chronic thrombi and signs of pulmonary hypertension. • On these index scans, the presence of ≥ 3 of 6 predefined radiological predictors was highly specific for a future diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), comparable to overall expert judgment. • Dedicated CTPA reading for signs of CTEPH may help in early detection of CTEPH after acute pulmonary embolism. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08364-0.
Collapse
|
12
|
Predictive value of chest HRCT for survival in idiopathic pulmonary arterial hypertension. Respir Res 2021; 22:293. [PMID: 34789251 PMCID: PMC8597242 DOI: 10.1186/s12931-021-01893-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 11/09/2021] [Indexed: 11/15/2022] Open
Abstract
Background Little attention has been paid to chest high resolution computed tomography (HRCT) findings in idiopathic pulmonary arterial hypertension (IPAH) patients so far, while a couple of small studies suggested that presence of centrilobular ground-glass opacifications (GGO) on lung scans could have a significant negative prognostic value. Therefore, the aims of the present study were: to assess frequency and clinical significance of GGO in IPAH, and to verify if it carries an add-on prognostic value in reference to multidimensional risk assessment tool recommended by the 2015 European pulmonary hypertension guidelines. Methods Chest HRCT scans of 110 IPAH patients were retrospectively analysed. Patients were divided into three groups: with panlobular (p)GGO, centrilobular (c)GGO, and normal lung pattern. Association of different GGO patterns with demographic, functional, haemodynamic, and biochemical parameters was tested. Survival analysis was also performed. Results GGO were found in 46% of the IPAH patients: pGGO in 24% and cGGO in 22%. Independent predictors of pGGO were: positive history of haemoptysis, higher number of low-risk factors, and lower cardiac output. Independent predictors of cGGO were: positive history of haemoptysis, younger age, higher right atrial pressure, and higher mixed venous blood oxygen saturation. CGGO had a negative prognostic value for outcome in a 2-year perspective. This effect was not seen in the longer term, probably due to short survival of cGGO patients. Conclusions Lung HRCT carries a significant independent prognostic information in IPAH, and in patients with cGGO present on the scans an early referral to lung transplantation centres should be considered.
Collapse
|
13
|
Boon GJAM, Jairam PM, Groot GMC, van Rooden CJ, Ende-Verhaar YM, Beenen LFM, Kroft LJM, Bogaard HJ, Huisman MV, Symersky P, Vonk Noordegraaf A, Meijboom LJ, Klok FA. Identification of chronic thromboembolic pulmonary hypertension on CTPAs performed for diagnosing acute pulmonary embolism depending on level of expertise. Eur J Intern Med 2021; 93:64-70. [PMID: 34294517 DOI: 10.1016/j.ejim.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/08/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Expert reading often reveals radiological signs of chronic thromboembolic pulmonary hypertension (CTEPH) or chronic PE on computed tomography pulmonary angiography (CTPA) performed at the time of acute pulmonary embolism (PE) presentation preceding CTEPH. Little is known about the accuracy and reproducibility of CTPA reading by radiologists in training in this setting. OBJECTIVES To evaluate 1) whether signs of CTEPH or chronic PE are routinely reported on CTPA for suspected PE; and 2) whether CTEPH-non-expert readers achieve comparable predictive accuracy to CTEPH-expert radiologists after dedicated instruction. METHODS Original reports of CTPAs demonstrating acute PE in 50 patients whom ultimately developed CTEPH, and those of 50 PE who did not, were screened for documented signs of CTEPH. All scans were re-assessed by three CTEPH-expert readers and two CTEPH-non-expert readers (blinded and independently) for predefined signs and overall presence of CTEPH. RESULTS Signs of chronic PE were mentioned in the original reports of 14/50 cases (28%), while CTEPH-expert radiologists had recognized 44/50 (88%). Using a standardized definition (≥3 predefined radiological signs), moderate-to-good agreement was reached between CTEPH-non-expert readers and the experts' consensus (k-statistics 0.46; 0.61) at slightly lower sensitivities. The CTEPH-non-expert readers had moderate agreement on the presence of CTEPH (κ-statistic 0.38), but both correctly identified most cases (80% and 88%, respectively). CONCLUSIONS Concomitant signs of CTEPH were poorly documented in daily practice, while most CTEPH patients were identified by CTEPH-non-expert readers after dedicated instruction. These findings underline the feasibility of achieving earlier CTEPH diagnosis by assessing CTPAs more attentively.
Collapse
Affiliation(s)
- Gudula J A M Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
| | - Pushpa M Jairam
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Gerie M C Groot
- Department of Radiology, Medical Center Gelderse Vallei, Ede, the Netherlands
| | | | - Yvonne M Ende-Verhaar
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Petr Symersky
- Department of Cardiothoracic Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| |
Collapse
|
14
|
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.
Collapse
|
15
|
Maier A, Liao SL, Lescure T, Robson PM, Hirata N, Sartori S, Narula N, Vergani V, Soultanidis G, Morgenthau A, Kovacic JC, Padilla M, Narula J, Jacobi A, Fayad ZA, Trivieri MG. Pulmonary Artery 18F-Fluorodeoxyglucose Uptake by PET/CMR as a Marker of Pulmonary Hypertension in Sarcoidosis. JACC Cardiovasc Imaging 2021; 15:108-120. [PMID: 34274283 DOI: 10.1016/j.jcmg.2021.05.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 05/25/2021] [Accepted: 05/26/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVES This study investigated whether pulmonary artery (PA) 18F-FDG uptake is associated with hypertension, and if it correlates to elevated pulmonary pressures. BACKGROUND 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) combined with computed tomography or cardiac magnetic resonance (CMR) has been used to assess inflammation mostly in large arteries of the systemic circulation. Much less is known about inflammation of the vasculature of the pulmonary system and its relationship to pulmonary hypertension (PH). METHODS In a single-center cohort of 175 patients with suspected cardiac sarcoidosis, who underwent hybrid thoracic PET/CMR, 18F-FDG uptake in the PA was quantified according to maximum standardized uptake value (SUVmax) and target-to-background ratio (TBR) and compared with available results from right heart catheterization (RHC) or transthoracic echocardiography (TTE). RESULTS Thirty-three subjects demonstrated clear 18F-FDG uptake in the PA wall. In the subgroup of patients who underwent RHC (n = 10), the mean PA pressure was significantly higher in the group with PA 18F-FDG uptake compared with the group without uptake (34.4 ± 7.2 mm Hg vs 25.6 ± 9.3 mm Hg; P = 0.003), and 9 (90%) patients with PA 18F-FDG uptake had PH when a mean PA pressure cutoff of 25 mm Hg was used compared with 18 (45%) in the nonuptake group (P < 0.05). In the subgroup that underwent TTE, signs of PH were present in a significantly higher number of patients with PA 18F-FDG uptake (14 [51.9%] vs 37 [29.8%]; P < 0.05). Qualitative assessment of 18F-FDG uptake in the PA wall showed a sensitivity of 33% and specificity of 96% for separating patients with PH based on RHC-derived PA pressures. SUVmax and TBR in the PA wall correlated with PA pressure derived from RHC and/or TTE. CONCLUSIONS We demonstrate that 18F-FDG uptake by PET/CMR in the PA is associated with PH and that its intensity correlates with PA pressure.
Collapse
Affiliation(s)
- Alexander Maier
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Cardiology and Angiology I, Heart Center Freiburg University, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steve Lin Liao
- Division of Noninvasive Cardiovascular Imaging at the Icahn School of Medicine at Mount Sinai, New York, USA
| | - Thomas Lescure
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Philip M Robson
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Naoki Hirata
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Samantha Sartori
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Navneet Narula
- Department of Pathology, New York University Langone Medical Center, New York, New York, USA
| | - Vittoria Vergani
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Georgios Soultanidis
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Morgenthau
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jason C Kovacic
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia; St Vincent's Clinical School, University of New South Wales, Darlinghurst, New South Wales, Australia
| | - Maria Padilla
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jagat Narula
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Adam Jacobi
- Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zahi A Fayad
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maria G Trivieri
- BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA; Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| |
Collapse
|
16
|
Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 248] [Impact Index Per Article: 82.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
Collapse
Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
| |
Collapse
|
17
|
Nasser M, Kolb M, Cottin V. Inhaled Treprostinil in Group 3 Pulmonary Hypertension. N Engl J Med 2021; 384:1871-1872. [PMID: 33979496 DOI: 10.1056/nejmc2103465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
18
|
Chandel A, Verster A, Rahim H, Khangoora V, Nathan SD, Ahmad K, Aryal S, Bagnola A, Singhal A, Brown AW, Shlobin OA, King CS. Incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension. Pulm Circ 2021; 11:20458940211012366. [PMID: 33996030 PMCID: PMC8108083 DOI: 10.1177/20458940211012366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 04/04/2021] [Indexed: 11/21/2022] Open
Abstract
It has been suggested pleural effusions may develop in right heart failure in the absence of left heart disease. The incidence and prognostic significance of pleural effusions in pulmonary arterial hypertension is uncertain. Patients with pulmonary arterial hypertension followed at our tertiary care center were reviewed. Survival was examined based on the subsequent development of a pleural effusion. A total of 191 patients with pulmonary arterial hypertension met the inclusion criteria. The prevalence of pleural effusions on initial assessment was 7.3%. Among patients without a pleural effusion on initial imaging and at least one follow-up computerized tomography (N = 142), pleural effusion developed in 27.5% (N = 39) of patients. No alternative etiology of the effusion was identified in 19 (48.7%) cases and effusions deemed related to pulmonary arterial hypertension occurred at an incident rate of 38.6 cases per 1000 person-years. Of these, 14 (73.7%) were bilateral, 3 (15.8%) were right-sided, and 2 (10.5%) were left-sided. Effusion size was trace or small in 18 patients (94.7%). Development of a new pleural effusion was associated with attenuated survival in unadjusted survival analysis (HR: 3.80; 95% CI: 1.55–9.31), multivariate analysis (HR: 5.13; 95% CI: 1.86–14.16), and after the multivariate model was adjusted for concomitant pericardial effusion (HR: 4.86; 95% CI: 1.51–15.71). Negative impact on survival remained unchanged when effusions more likely related to an alternative cause were removed from analysis. In conclusion, pleural effusions can complicate pulmonary arterial hypertension in the absence of left heart disease. These effusions are frequently small in size, bilateral in location, and their presence is associated with decreased survival. Attenuated survival appears independent of the risk associated with a new pericardial effusion.
Collapse
Affiliation(s)
- Abhimanyu Chandel
- Department of Pulmonology and Critical Care, Walter Reed National Military Medical Center, Bethesda, MD, USA
| | - Alison Verster
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Husna Rahim
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Vikramjit Khangoora
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Kareem Ahmad
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Shambhu Aryal
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Aaron Bagnola
- Department of Pharmacy, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Anju Singhal
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - A Whitney Brown
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Christopher S King
- Advanced Lung Disease and Transplant Center, Inova Fairfax Hospital, Falls Church, VA, USA
| |
Collapse
|
19
|
Dwivedi K, Sharkey M, Condliffe R, Uthoff JM, Alabed S, Metherall P, Lu H, Wild JM, Hoffman EA, Swift AJ, Kiely DG. Pulmonary Hypertension in Association with Lung Disease: Quantitative CT and Artificial Intelligence to the Rescue? State-of-the-Art Review. Diagnostics (Basel) 2021; 11:diagnostics11040679. [PMID: 33918838 PMCID: PMC8070579 DOI: 10.3390/diagnostics11040679] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/05/2021] [Accepted: 04/05/2021] [Indexed: 12/24/2022] Open
Abstract
Accurate phenotyping of patients with pulmonary hypertension (PH) is an integral part of informing disease classification, treatment, and prognosis. The impact of lung disease on PH outcomes and response to treatment remains a challenging area with limited progress. Imaging with computed tomography (CT) plays an important role in patients with suspected PH when assessing for parenchymal lung disease, however, current assessments are limited by their semi-qualitative nature. Quantitative chest-CT (QCT) allows numerical quantification of lung parenchymal disease beyond subjective visual assessment. This has facilitated advances in radiological assessment and clinical correlation of a range of lung diseases including emphysema, interstitial lung disease, and coronavirus disease 2019 (COVID-19). Artificial Intelligence approaches have the potential to facilitate rapid quantitative assessments. Benefits of cross-sectional imaging include ease and speed of scan acquisition, repeatability and the potential for novel insights beyond visual assessment alone. Potential clinical benefits include improved phenotyping and prediction of treatment response and survival. Artificial intelligence approaches also have the potential to aid more focused study of pulmonary arterial hypertension (PAH) therapies by identifying more homogeneous subgroups of patients with lung disease. This state-of-the-art review summarizes recent QCT developments and potential applications in patients with PH with a focus on lung disease.
Collapse
Affiliation(s)
- Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Correspondence:
| | - Michael Sharkey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Robin Condliffe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Johanna M. Uthoff
- Department of Computer Science, University of Sheffield, Sheffield S1 4DP, UK; (J.M.U.); (H.L.)
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
| | - Peter Metherall
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
| | - Haiping Lu
- Department of Computer Science, University of Sheffield, Sheffield S1 4DP, UK; (J.M.U.); (H.L.)
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - Jim M. Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - Eric A. Hoffman
- Advanced Pulmonary Physiomic Imaging Laboratory, University of Iowa, C748 GH, Iowa City, IA 52242, USA;
| | - Andrew J. Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| | - David G. Kiely
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield S10 2RX, UK; (M.S.); (R.C.); (S.A.); (P.M.); (J.M.W.); (A.J.S.); (D.G.K.)
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield S1 3JD, UK
| |
Collapse
|
20
|
Schattner A. Associated Pleural and Pericardial Effusions: An Extensive Differential Explored. Am J Med 2021; 134:435-443.e5. [PMID: 33181104 DOI: 10.1016/j.amjmed.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 10/28/2020] [Accepted: 11/02/2020] [Indexed: 01/30/2023]
Abstract
Concurrent pleural and pericardial effusions are not an unusual finding, but their differential diagnosis remains uncertain. Medline-based review identified an extensive list of infectious, inflammatory, neoplastic, iatrogenic, and myriad other etiologies. A single retrospective study had addressed this presentation. Several principles of a diagnostic workup are suggested, acknowledging that a significant minority of patients may not require a comprehensive workup and remain 'idiopathic'.
Collapse
Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Jerusalem, Israel.
| |
Collapse
|
21
|
Swift AJ, Lu H, Uthoff J, Garg P, Cogliano M, Taylor J, Metherall P, Zhou S, Johns CS, Alabed S, Condliffe RA, Lawrie A, Wild JM, Kiely DG. A machine learning cardiac magnetic resonance approach to extract disease features and automate pulmonary arterial hypertension diagnosis. Eur Heart J Cardiovasc Imaging 2021; 22:236-245. [PMID: 31998956 PMCID: PMC7822638 DOI: 10.1093/ehjci/jeaa001] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/06/2019] [Accepted: 01/03/2020] [Indexed: 12/18/2022] Open
Abstract
AIMS Pulmonary arterial hypertension (PAH) is a progressive condition with high mortality. Quantitative cardiovascular magnetic resonance (CMR) imaging metrics in PAH target individual cardiac structures and have diagnostic and prognostic utility but are challenging to acquire. The primary aim of this study was to develop and test a tensor-based machine learning approach to holistically identify diagnostic features in PAH using CMR, and secondarily, visualize and interpret key discriminative features associated with PAH. METHODS AND RESULTS Consecutive treatment naive patients with PAH or no evidence of pulmonary hypertension (PH), undergoing CMR and right heart catheterization within 48 h, were identified from the ASPIRE registry. A tensor-based machine learning approach, multilinear subspace learning, was developed and the diagnostic accuracy of this approach was compared with standard CMR measurements. Two hundred and twenty patients were identified: 150 with PAH and 70 with no PH. The diagnostic accuracy of the approach was high as assessed by area under the curve at receiver operating characteristic analysis (P < 0.001): 0.92 for PAH, slightly higher than standard CMR metrics. Moreover, establishing the diagnosis using the approach was less time-consuming, being achieved within 10 s. Learnt features were visualized in feature maps with correspondence to cardiac phases, confirming known and also identifying potentially new diagnostic features in PAH. CONCLUSION A tensor-based machine learning approach has been developed and applied to CMR. High diagnostic accuracy has been shown for PAH diagnosis and new learnt features were visualized with diagnostic potential.
Collapse
Affiliation(s)
- Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
- INSIGNEO, Institute for In Silico Medicine, The University of Sheffield, The Pam Liversidge Building, Sir Frederick Mappin Building, F Floor, Mappin Street, Sheffield, S1 3JD, UK
| | - Haiping Lu
- INSIGNEO, Institute for In Silico Medicine, The University of Sheffield, The Pam Liversidge Building, Sir Frederick Mappin Building, F Floor, Mappin Street, Sheffield, S1 3JD, UK
- Department of Computer Science, The University of Sheffield, 211 Portobello, Sheffield, S1 4DP, UK
| | - Johanna Uthoff
- Department of Computer Science, The University of Sheffield, 211 Portobello, Sheffield, S1 4DP, UK
| | - Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - Marcella Cogliano
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - Jonathan Taylor
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| | - Peter Metherall
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| | - Shuo Zhou
- Department of Computer Science, The University of Sheffield, 211 Portobello, Sheffield, S1 4DP, UK
| | - Christopher S Johns
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| | - Samer Alabed
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| | - Robin A Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| | - Allan Lawrie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Western Bank, Sheffield S10 2TN, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Glossop Rd, Sheffield S10 2JF, UK
| |
Collapse
|
22
|
Foley RW, Kaneria N, Ross RVM, Suntharalingam J, Hudson BJ, Rodrigues JC, Robinson G. Computed tomography appearances of the lung parenchyma in pulmonary hypertension. Br J Radiol 2021; 94:20200830. [PMID: 32915646 DOI: 10.1259/bjr.20200830] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Computed tomography (CT) is a valuable tool in the workup of patients under investigation for pulmonary hypertension (PH) and may be the first test to suggest the diagnosis. CT parenchymal lung changes can help to differentiate the aetiology of PH. CT can demonstrate interstitial lung disease, emphysema associated with chronic obstructive pulmonary disease, features of left heart failure (including interstitial oedema), and changes secondary to miscellaneous conditions such as sarcoidosis. CT also demonstrates parenchymal changes secondary to chronic thromboembolic disease and venous diseases such as pulmonary venous occlusive disease (PVOD) and pulmonary capillary haemangiomatosis (PCH). It is important for the radiologist to be aware of the various manifestations of PH in the lung, to help facilitate an accurate and timely diagnosis. This pictorial review illustrates the parenchymal lung changes that can be seen in the various conditions causing PH.
Collapse
Affiliation(s)
- Robert W Foley
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Nirav Kaneria
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Rob V MacKenzie Ross
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Jay Suntharalingam
- Department of Respiratory Medicine, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Benjamin J Hudson
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Jonathan Cl Rodrigues
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| | - Graham Robinson
- Department of Radiology, Royal United Hospitals Bath NHS Foundation Trust, Combe Park, Avon, Bath, United Kingdom
| |
Collapse
|
23
|
Hemnes A, Rothman AMK, Swift AJ, Zisman LS. Role of biomarkers in evaluation, treatment and clinical studies of pulmonary arterial hypertension. Pulm Circ 2020; 10:2045894020957234. [PMID: 33282185 PMCID: PMC7682212 DOI: 10.1177/2045894020957234] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022] Open
Abstract
Pulmonary arterial hypertension is a complex disease resulting from the interplay of myriad biological and environmental processes that lead to remodeling of the pulmonary vasculature with consequent pulmonary hypertension. Despite currently available therapies, there remains significant morbidity and mortality in this disease. There is great interest in identifying and applying biomarkers to help diagnose patients with pulmonary arterial hypertension, inform prognosis, guide therapy, and serve as surrogate endpoints. An extensive literature on potential biomarker candidates is available, but barriers to the implementation of biomarkers for clinical use in pulmonary arterial hypertension are substantial. Various omic strategies have been undertaken to identify key pathways regulated in pulmonary arterial hypertension that could serve as biomarkers including genomic, transcriptomic, proteomic, and metabolomic approaches. Other biologically relevant components such as circulating cells, microRNAs, exosomes, and cell-free DNA have recently been gaining attention. Because of the size of the datasets generated by these omic approaches and their complexity, artificial intelligence methods are being increasingly applied to decipher their meaning. There is growing interest in imaging the lung with various modalities to understand and visualize processes in the lung that lead to pulmonary vascular remodeling including high resolution computed tomography, Xenon magnetic resonance imaging, and positron emission tomography. Such imaging modalities have the potential to demonstrate disease modification resulting from therapeutic interventions. Because right ventricular function is a major determinant of prognosis, imaging of the right ventricle with echocardiography or cardiac magnetic resonance imaging plays an important role in the evaluation of patients and may also be useful in clinical studies of pulmonary arterial hypertension.
Collapse
Affiliation(s)
- Anna Hemnes
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Andrew J Swift
- University of Sheffield and Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | | |
Collapse
|
24
|
Glick M, Baxter C, Lopez D, Mufti K, Sawada S, Lahm T. Releasing the brakes: a case report of pulmonary arterial hypertension induced by immune checkpoint inhibitor therapy. Pulm Circ 2020; 10:2045894020960967. [PMID: 33240485 PMCID: PMC7675877 DOI: 10.1177/2045894020960967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/30/2020] [Indexed: 11/16/2022] Open
Abstract
Immune checkpoint inhibitors successfully treat various malignancies by inducing an immune response to tumor cells. However, their use has been associated with a variety of autoimmune disorders, such as diabetes, hepatitis, and pneumonitis. Pulmonary arterial hypertension due to checkpoint inhibitor use has not yet been described. We present a novel case of pulmonary arterial hypertension associated with systemic lupus erythematosus and Sjogren's syndrome overlap that was induced by therapy with the checkpoint inhibitor durvalumab.
Collapse
Affiliation(s)
- Matthew Glick
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Chase Baxter
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - David Lopez
- Internal Medicine Residency Program, Department of Medicine, Indiana University School of Medicine, Indianapolis, USA
| | - Kashif Mufti
- Department of Medicine, Division of Rheumatology, Indiana University School of Medicine, Indianapolis, USA
| | - Stephen Sawada
- Department of Medicine, Krannert Institute of Cardiology, Indiana University School of Medicine, Indianapolis, USA
| | - Tim Lahm
- Department of Medicine, Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, USA.,Richard L. Roudebush VA Medical Center, Indianapolis, USA
| |
Collapse
|
25
|
Beijk MAM, de Winter RJ. Predicting the outcomes of pulmonary hypertension is a breathtaking task. Neth Heart J 2020; 28:623-624. [PMID: 33113103 PMCID: PMC7683663 DOI: 10.1007/s12471-020-01512-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- M A M Beijk
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.
| | - R J de Winter
- Department of Cardiology, Heart Center, Amsterdam UMC, University of Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| |
Collapse
|
26
|
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.
Collapse
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
| |
Collapse
|
27
|
Role of Cardiovascular CT in Pulmonary Hypertension. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00354-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
28
|
Swift AJ, Dwivedi K, Johns C, Garg P, Chin M, Currie BJ, Rothman AM, Capener D, Shahin Y, Elliot CA, Charalampopolous T, Sabroe I, Rajaram S, Hill C, Wild JM, Condliffe R, Kiely DG. Diagnostic accuracy of CT pulmonary angiography in suspected pulmonary hypertension. Eur Radiol 2020; 30:4918-4929. [PMID: 32342182 PMCID: PMC7431437 DOI: 10.1007/s00330-020-06846-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/23/2019] [Accepted: 03/30/2020] [Indexed: 01/29/2023]
Abstract
Objectives Computed tomography (CT) pulmonary angiography is widely used in patients with suspected pulmonary hypertension (PH). However, the diagnostic and prognostic significance remains unclear. The aim of this study was to (a) build a diagnostic CT model and (b) test its prognostic significance. Methods Consecutive patients with suspected PH undergoing routine CT pulmonary angiography and right heart catheterisation (RHC) were identified. Axial and reconstructed images were used to derive CT metrics. Multivariate regression analysis was performed in the derivation cohort to identify a diagnostic CT model to predict mPAP ≥ 25 mmHg (the existing ESC guideline definition of PH) and > 20 mmHg (the new threshold proposed at the 6th World Symposium on PH). In the validation cohort, sensitivity, specificity and compromise CT thresholds were identified with receiver operating characteristic (ROC) analysis. The prognostic value of the CT model was assessed using Kaplan-Meier analysis. Results Between 2012 and 2016, 491 patients were identified. In the derivation cohort (n = 247), a CT model was identified including pulmonary artery diameter, right ventricular outflow tract thickness, septal angle and left ventricular area. In the validation cohort (n = 244), the model was diagnostic, with an area under the ROC curve of 0.94/0.91 for mPAP ≥ 25/> 20 mmHg respectively. In the validation cohort, 93 patients died; mean follow-up was 42 months. The diagnostic thresholds for the CT model were prognostic, log rank, all p < 0.01. Discussion In suspected PH, a diagnostic CT model had diagnostic and prognostic utility. Key Points • Diagnostic CT models have high diagnostic accuracy in a tertiary referral population of with suspected PH. • Diagnostic CT models stratify patients by mortality in suspected PH. Electronic supplementary material The online version of this article (10.1007/s00330-020-06846-1) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK. .,INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, UK. .,Academic Unit of Radiology, University of Sheffield, C Floor, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
| | - Krit Dwivedi
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Chris Johns
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Pankaj Garg
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Matthew Chin
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Ben J Currie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Alex Mk Rothman
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Dave Capener
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Yousef Shahin
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Thanos Charalampopolous
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Sabroe
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Smitha Rajaram
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Radiology Department, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - David G Kiely
- INSIGNEO, Institute for In Silico Medicine, University of Sheffield, Sheffield, UK.,Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| |
Collapse
|
29
|
Tanguay VF, Babin C, Giardetti G, Sohier-Poirier C, Ménard-Cholette V, Ranchoux B, Ruffenach G, Montani D, Bonnet S, Provencher S. Enhanced Pulmonary Artery Radiodensity in Pulmonary Arterial Hypertension: A Sign of Early Calcification? Am J Respir Crit Care Med 2020; 199:799-802. [PMID: 30571924 DOI: 10.1164/rccm.201806-1027le] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Virginie F Tanguay
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Camille Babin
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Gabrielle Giardetti
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Catherine Sohier-Poirier
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Vincent Ménard-Cholette
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Benoît Ranchoux
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Grégoire Ruffenach
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | | | - Sébastien Bonnet
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| | - Steeve Provencher
- 1 Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec Québec, Québec, Canada.,2 Université Laval Québec, Québec, Canada and
| |
Collapse
|
30
|
Abstract
Pulmonary arterial hypertension (PAH) is rare and, if untreated, has a median survival of 2-3 years. Pulmonary arterial hypertension may be idiopathic (IPAH) but is frequently associated with other conditions. Despite increased awareness, therapeutic advances, and improved outcomes, the time from symptom onset to diagnosis remains unchanged. The commonest symptoms of PAH (breathlessness and fatigue) are non-specific and clinical signs are usually subtle, frequently preventing early diagnosis where therapies may be more effective. The failure to improve the time to diagnosis largely reflects an inability to identify patients at increased risk of PAH using current approaches. To date, strategies to improve the time to diagnosis have focused on screening patients with a high prevalence [systemic sclerosis (10%), patients with portal hypertension assessed for liver transplantation (2-6%), carriers of mutations of the gene encoding bone morphogenetic protein receptor type II, and first-degree relatives of patients with heritable PAH]. In systemic sclerosis, screening algorithms have demonstrated that patients can be identified earlier, however, current approaches are resource intensive. Until, recently, it has not been considered possible to screen populations for rare conditions such as IPAH (prevalence 5-15/million/year). However, there is interest in the use of artificial intelligence approaches in medicine and the application of diagnostic algorithms to large healthcare data sets, to identify patients at risk of rare conditions. In this article, we review current approaches and challenges in screening for PAH and explore novel population-based approaches to improve detection.
Collapse
Affiliation(s)
- David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, S10 2JF, UK
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, S10 2RX, UK
- Insigneo Institute for in silico Medicine, Sheffield, S1 3JD, UK
| | - Allan Lawrie
- Department of Infection, Immunity & Cardiovascular Disease, University of Sheffield, Sheffield, S10 2RX, UK
- Insigneo Institute for in silico Medicine, Sheffield, S1 3JD, UK
| | - Marc Humbert
- Univ. Paris–Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France
- AP-HP, Service de Pneumologie, Centre de Référence de l’Hypertension Pulmonaire, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis Robinson, France
| |
Collapse
|
31
|
Huang L, Li J, Huang M, Zhuang J, Yuan H, Jia Q, Zeng D, Que L, Xi Y, Lin J, Dong Y. Prediction of pulmonary pressure after Glenn shunts by computed tomography-based machine learning models. Eur Radiol 2019; 30:1369-1377. [PMID: 31705256 DOI: 10.1007/s00330-019-06502-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/21/2019] [Accepted: 10/03/2019] [Indexed: 12/23/2022]
Abstract
OBJECTIVES This study aimed to develop non-invasive machine learning classifiers for predicting post-Glenn shunt patients with low and high risks of a mean pulmonary arterial pressure (mPAP) > 15 mmHg based on preoperative cardiac computed tomography (CT). METHODS This retrospective study included 96 patients with functional single ventricle who underwent a bidirectional Glenn procedure between November 1, 2009, and July, 31, 2017. All patients underwent post-procedure CT, followed by cardiac catheterization. Overall, 23 morphologic parameters were manually extracted from cardiac CT images for each patient. The Mann-Whitney U or chi-square test was applied to select the most significant predictors. Six machine learning algorithms including logistic regression, Naive Bayes, random forest (RF), linear discriminant analysis, support vector machine, and K-nearest neighbor were used for modeling. These algorithms were independently trained on 100 train-validation random splits with a 3:1 ratio. Their average performance was evaluated by area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS Seven CT morphologic parameters were selected for modeling. RF obtained the best performance, with mean AUC of 0.840 (confidence interval [CI] 0.832-0.850) and 0.787 (95% CI 0.780-0.794); sensitivity of 0.815 (95% CI 0.797-0.833) and 0.778 (95% CI 0.767-0.788), specificity of 0.766 (95% CI 0.748-0.785) and 0.746 (95% CI 0.735-0.757); and accuracy of 0.782 (95% CI 0.771-0.793) and 0.756 (95% CI 0.748-0.764) in the training and validation cohorts, respectively. CONCLUSIONS The CT-based RF model demonstrates a good performance in the prediction of mPAP, which may reduce the need for right heart catheterization in post-Glenn shunt patients with suspected mPAP > 15 mmHg. KEY POINTS • Twenty-three candidate descriptors were manually extracted from cardiac computed tomography images, and seven of them were selected for subsequent modeling. • The random forest model presents the best predictive performance for pulmonary pressure among all methods. • The computed tomography-based machine learning model could predict post-Glenn shunt pulmonary pressure non-invasively.
Collapse
Affiliation(s)
- Lei Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China.,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jiahua Li
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Meiping Huang
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Jian Zhuang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Haiyun Yuan
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Qianjun Jia
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
| | - Dewen Zeng
- Huazhong University of Science and Technology, Wuhan, People's Republic of China
| | - Lifeng Que
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Yue Xi
- Department of Radiology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, People's Republic of China
| | - Jijin Lin
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, People's Republic of China. .,The Second School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, People's Republic of China.
| | - Yuhao Dong
- Department of Catheterization Lab, Guangdong Cardiovascular Institute, Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China.
| |
Collapse
|
32
|
Abstract
PURPOSE OF REVIEW Pulmonary hypertension is a life-shortening condition, which may be idiopathic but is more frequently seen in association with other conditions. Current guidelines recommend cardiac catheterization to confirm the diagnosis of pulmonary hypertension. Evidence suggests an increasing role for noninvasive imaging modalities in the initial diagnostic and prognostic assessment and evaluation of treatment response. RECENT FINDINGS In this review we examine the evidence for current noninvasive imaging methodologies: echocardiography computed tomography and MRI in the diagnostic and prognostic assessment of suspected pulmonary hypertension and explore the potential utility of modeling and machine-learning approaches. SUMMARY Noninvasive imaging allows a comprehensive assessment of patients with suspected pulmonary hypertension. It plays a key part in the initial diagnostic and prognostic assessment and machine-learning approaches show promise in the diagnosis of pulmonary hypertension.
Collapse
|
33
|
Coste F, Benlala I, Dournes G, Girodet PO, Laurent F, Berger P. Assessing pulmonary hypertension in COPD. Is there a role for computed tomography? Int J Chron Obstruct Pulmon Dis 2019; 14:2065-2079. [PMID: 31564854 PMCID: PMC6732516 DOI: 10.2147/copd.s207363] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Accepted: 06/10/2019] [Indexed: 12/22/2022] Open
Abstract
Pulmonary hypertension (PH) is a common complication of chronic obstructive pulmonary disease (COPD) and is associated with increased morbidity and mortality. Reference standard method to diagnose PH is right heart catheterization. Several non-invasive imaging techniques have been employed in the detection of PH. Among them, computed tomography (CT) is the most commonly used for phenotyping and detecting complications of COPD. Several CT findings have also been described in patients with severe PH. Nevertheless, CT analysis is currently based on visual findings which can lead to reproducibility failure. Therefore, there is a need for quantification in order to assess objective criteria. In this review, progresses in automated analyses of CT parameters and their values in predicting PH and COPD outcomes are presented.
Collapse
Affiliation(s)
- Florence Coste
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France
| | - Ilyes Benlala
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France.,CHU de Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, CIC1401, Service d'Explorations Fonctionnelles Respiratoires, Pessac, F-33600 France
| | - Gaël Dournes
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France.,CHU de Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, CIC1401, Service d'Explorations Fonctionnelles Respiratoires, Pessac, F-33600 France
| | - Pierre-Olivier Girodet
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France.,CHU de Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, CIC1401, Service d'Explorations Fonctionnelles Respiratoires, Pessac, F-33600 France
| | - François Laurent
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France.,CHU de Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, CIC1401, Service d'Explorations Fonctionnelles Respiratoires, Pessac, F-33600 France
| | - Patrick Berger
- University Bordeaux, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Bordeaux, F-33000 France.,Inserm, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, CIC1401, Bordeaux, F-33000 France.,CHU de Bordeaux, Service d'Imagerie Thoracique et Cardiovasculaire, Service des Maladies Respiratoires, CIC1401, Service d'Explorations Fonctionnelles Respiratoires, Pessac, F-33600 France
| |
Collapse
|
34
|
Abstract
In early 2019, the 6th World Symposium on Pulmonary Hypertension (WSPH) released an updated document highlighting the advances in the last five years. During the quinquennial event many experts worked together to suggest new changes in the disease diagnosis and management. Since inception of the WSPH in 1973, this is the first time when the hemodynamic definition of pulmonary hypertension (PH) has been updated. These proceedings have re-defined the different hemodynamic types of PH that occur with the left heart disease along with introduction to the genetic testing as part of pulmonary arterial hypertension (PAH) evaluation. Objective of this review is to highlight the evaluation and diagnosis of PAH based on the proceedings of the 6th WSPH. Accurate early diagnosis and subsequent management of PH is necessary, as despite of treatment advances, survival remains suboptimal.
Collapse
Affiliation(s)
- Sandeep Sahay
- Division of Pulmonary and Critical Care Medicine, Weill Cornell Medical College, Institute of Academic Medicine, Houston Methodist Hospital, Houston, TX, USA
| |
Collapse
|
35
|
Lai YJ, Chen PR, Huang YL, Hsu HH. Unique wreath-like smooth muscle proliferation of the pulmonary vasculature in pulmonary veno-occlusive disease versus pulmonary arterial hypertension. J Formos Med Assoc 2019; 119:300-309. [PMID: 31202500 DOI: 10.1016/j.jfma.2019.05.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/06/2019] [Accepted: 05/22/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND/PURPOSE Pulmonary veno-occlusive disease (PVOD) is a rare but fatal cause of pulmonary hypertension reported to be linked to mutations of eukaryotic initiation factor 2 alpha kinase 4 (EIF2AK4), also known as general control nonderepressible 2 kinase (GCN2). PVOD is difficult to diagnose and often initially misdiagnosed as other types of idiopathic pulmonary arterial hypertension (IPAH). To rapidly and correctly identify PVOD patients and explore the possible pathogenesis, we thoroughly investigated histopathological features and GCN2 protein levels in non-PAH, PVOD and PAH patients. METHODS Lung specimens were examined for histopathological changes, including those of pulmonary arteries and veins, by Masson's trichrome, modified Verhoeff's and α-SMA staining in the PVOD, IPAH, and non-PAH groups. GCN2 and α-SMA expression in lung tissue was examined by immunohistochemistry and western blotting. RESULTS PVOD and IPAH patients showed significant intimal and medial thickening of muscular pulmonary arteries compared with non-PAH patients. PVOD patients had more prominent intimal and medial thickening of muscular pulmonary veins than the other two groups. Interestingly, specialized muscle bundles surrounding the tunica adventitia of the pulmonary artery and vein were observed in PVOD patients. A significant decrease in GCN2 expression in the PVOD group was confirmed by immunohistochemistry and western blotting. CONCLUSION Our study is the first to show remarkable histological structures, including the wreath-like arrangement of a hyperplastic muscle bundle in the adventitia of pulmonary arteries, in PVOD patients as a diagnostic clue and to disclose the biological difference between PAH and PVOD in a Taiwanese population.
Collapse
Affiliation(s)
- Ying-Ju Lai
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Tao-Yuan, 33353, Taiwan; Cardiovascular Division, Chang Gung Memorial Hospital, Tao-Yuan, 33353, Taiwan; Department of Respiratory Care, Chang-Gung University of Science and Technology, Chia-Yi, 61363, Taiwan
| | - Po-Ru Chen
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Tao-Yuan, 33353, Taiwan
| | - Yen-Lin Huang
- Department of Pathology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan
| | - Hsao-Hsun Hsu
- Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 10002, Taiwan.
| |
Collapse
|
36
|
Computed tomographic and clinical features of pulmonary veno-occlusive disease: raising the radiologist's awareness. Clin Radiol 2019; 74:655-662. [PMID: 31178067 DOI: 10.1016/j.crad.2019.04.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/26/2019] [Indexed: 11/22/2022]
Abstract
Pulmonary veno-occlusive disease (PVOD) is a rare subtype of pulmonary arterial hypertension (PAH) characterised by preferential remodelling of the pulmonary venules. Differentiation from other subtypes of PAH is essential as the management can differ significantly; for example, initiation of vasodilator therapy may cause fatal pulmonary oedema in a patient with PVOD misdiagnosed with idiopathic PAH. PVOD also carries a substantially worse prognosis. Lung biopsy is required for definitive diagnosis, but this is hazardous, and ideally, should be avoided in pulmonary hypertension. Computed tomography (CT) may suggest the diagnosis, directing the patient towards specialist review. Potential distinguishing CT features between PVOD and other subtypes of PAH include interlobular septal thickening, mediastinal lymphadenopathy, and centrilobular ground-glass opacities. No evidence-based medical therapy exists for PVOD at present and lung transplantation remains the definitive treatment for eligible patients. Therefore, early radiological identification of this challenging diagnosis facilitates timely referral for transplant.
Collapse
|
37
|
Imaging of Pulmonary Hypertension: Pictorial Essay. Chest 2019; 156:211-227. [PMID: 30981724 DOI: 10.1016/j.chest.2019.04.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 04/01/2019] [Indexed: 11/20/2022] Open
Abstract
Pulmonary hypertension (PH) is an end result of a diverse array of complex clinical conditions that invoke hemodynamic and pathophysiological changes in the pulmonary vasculature. Many patients' symptoms begin with dyspnea on exertion for which screening tests such as chest roentgenograms and more definitive noninvasive tests such as CT scans are ordered initially. It is imperative that clinicians are cognizant of subtle clues on these imaging modalities that alert them to the possibility of PH. These clues may serve as a stepping stone towards more advanced noninvasive (echocardiogram) and invasive (right heart catheterization) testing. On the CT scan, the signs are classified into mediastinal and lung parenchymal abnormalities. In addition to suspecting the diagnosis of PH, this paper provides a pictorial essay to guide health care professionals in identifying the etiology of PH. This paper also provides concrete definitions, wherever possible, of what constitutes abnormalities in PH, such as dilated pulmonary arteries, pruning of vessels, and increased thickness of free wall of the right ventricle. The sensitivities and specificities of each sign are enumerated. The common radiographic and clinical features of many different etiologies of PH are tabulated for the convenience of the readers. Some newer imaging modalities such as dual-energy CT of the chest that hold promise for the future are also described.
Collapse
|
38
|
Ferreiro L, Álvarez-Dobaño JM, Valdés L. Can Right Heart Failure Cause Pleural Effusion? Arch Bronconeumol 2019; 55:453-454. [PMID: 30971367 DOI: 10.1016/j.arbres.2019.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/15/2019] [Accepted: 02/11/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Lucía Ferreiro
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España.
| | - José Manuel Álvarez-Dobaño
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| | - Luis Valdés
- Servicio de Neumología, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, La Coruña, España; Grupo Interdisciplinar de Investigación en Neumología, Instituto de Investigaciones Sanitarias de Santiago (IDIS), Santiago de Compostela, La Coruña, España
| |
Collapse
|
39
|
Kiely DG, Levin DL, Hassoun PM, Ivy D, Jone PN, Bwika J, Kawut SM, Lordan J, Lungu A, Mazurek JA, Moledina S, Olschewski H, Peacock AJ, Puri G, Rahaghi FN, Schafer M, Schiebler M, Screaton N, Tawhai M, van Beek EJ, Vonk-Noordegraaf A, Vandepool R, Wort SJ, Zhao L, Wild JM, Vogel-Claussen J, Swift AJ. EXPRESS: Statement on imaging and pulmonary hypertension from the Pulmonary Vascular Research Institute (PVRI). Pulm Circ 2019; 9:2045894019841990. [PMID: 30880632 PMCID: PMC6732869 DOI: 10.1177/2045894019841990] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/01/2019] [Indexed: 01/08/2023] Open
Abstract
Pulmonary hypertension (PH) is highly heterogeneous and despite treatment advances it remains a life-shortening condition. There have been significant advances in imaging technologies, but despite evidence of their potential clinical utility, practice remains variable, dependent in part on imaging availability and expertise. This statement summarizes current and emerging imaging modalities and their potential role in the diagnosis and assessment of suspected PH. It also includes a review of commonly encountered clinical and radiological scenarios, and imaging and modeling-based biomarkers. An expert panel was formed including clinicians, radiologists, imaging scientists, and computational modelers. Section editors generated a series of summary statements based on a review of the literature and professional experience and, following consensus review, a diagnostic algorithm and 55 statements were agreed. The diagnostic algorithm and summary statements emphasize the key role and added value of imaging in the diagnosis and assessment of PH and highlight areas requiring further research.
Collapse
Affiliation(s)
- David G. Kiely
- Sheffield Pulmonary Vascular Disease
Unit, Royal Hallamshire Hospital, Sheffield, UK
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
| | - David L. Levin
- Department of Radiology, Mayo Clinic,
Rochester, MN, USA
| | - Paul M. Hassoun
- Department of Medicine John Hopkins
University, Baltimore, MD, USA
| | - Dunbar Ivy
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Pei-Ni Jone
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | | | - Steven M. Kawut
- Department of Medicine, Perelman School
of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jim Lordan
- Freeman Hospital, Newcastle Upon Tyne,
Newcastle, UK
| | - Angela Lungu
- Technical University of Cluj-Napoca,
Cluj-Napoca, Romania
| | - Jeremy A. Mazurek
- Division of Cardiovascular Medicine,
Hospital
of the University of Pennsylvania,
Philadelphia, PA, USA
| | | | - Horst Olschewski
- Division of Pulmonology, Ludwig
Boltzmann Institute Lung Vascular Research, Graz, Austria
| | - Andrew J. Peacock
- Scottish Pulmonary Vascular Disease,
Unit, University of Glasgow, Glasgow, UK
| | - G.D. Puri
- Department of Anaesthesiology and
Intensive Care, Post Graduate Institute of Medical Education and Research,
Chandigarh, India
| | - Farbod N. Rahaghi
- Brigham and Women’s Hospital, Harvard
Medical School, Boston, MA, USA
| | - Michal Schafer
- Paediatric Cardiology, Children’s
Hospital, University of Colorado School of Medicine, Denver, CO, USA
| | - Mark Schiebler
- Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | - Merryn Tawhai
- Auckland Bioengineering Institute,
Auckland, New Zealand
| | - Edwin J.R. van Beek
- Edinburgh Imaging, Queens Medical
Research Institute, University of Edinburgh, Edinburgh, UK
| | | | - Rebecca Vandepool
- University of Arizona, Division of
Translational and Regenerative Medicine, Tucson, AZ, USA
| | - Stephen J. Wort
- Royal Brompton Hospital, London,
UK
- Imperial College, London, UK
| | | | - Jim M. Wild
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| | - Jens Vogel-Claussen
- Institute of diagnostic and
Interventional Radiology, Medical Hospital Hannover, Hannover, Germany
| | - Andrew J. Swift
- Department of Infection, Immunity and
Cardiovascular Disease and Insigneo Institute, University of Sheffield, Sheffield,
UK
- Academic Department of Radiology,
University of Sheffield, Sheffield, UK
| |
Collapse
|
40
|
Toya T, Nagatomo Y, Kagami K, Yukino M, Yasuda R, Namba T, Ido Y, Kobayashi S, Masaki N, Yada H, Kimura F, Adachi T. Computed tomography-measured pulmonary artery to aorta ratio and EUTOS score for detecting dasatinib-induced pulmonary arterial hypertension. Int J Cardiovasc Imaging 2019; 35:1435-1442. [DOI: 10.1007/s10554-019-01548-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 01/24/2019] [Indexed: 01/10/2023]
|
41
|
Johns CS, Wild JM, Rajaram S, Swift AJ, Kiely DG. Current and emerging imaging techniques in the diagnosis and assessment of pulmonary hypertension. Expert Rev Respir Med 2019; 12:145-160. [PMID: 29261337 DOI: 10.1080/17476348.2018.1420478] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary hypertension (PH) is a challenging condition to diagnose and treat. Over the last two decades, there have been significant advances in therapeutic approaches and imaging technologies. Current guidelines emphasize the importance of cardiac catheterization; however, the increasing availability of non-invasive imaging has the potential to improve diagnostic rates, whilst providing additional information on patient phenotypes. Areas covered: This review discusses the role of imaging in the diagnosis, prognostic assessment and follow-up of patients with PH. Imaging methods, ranging from established investigations (chest radiography, echocardiography, nuclear medicine and computerized tomography (CT)), to emerging modalities (dual energy CT, magnetic resonance imaging (MRI), optical coherence tomography and positron emission tomography (PET)) are reviewed. The value and limitations of the clinical utility of these imaging modalities and their potential clinical application are reviewed. Expert commentary: Imaging plays a key role in the diagnosis and classification of pulmonary hypertension. It also provides valuable prognostic information and emerging evidence supports a role for serial assessments. The authors anticipate an increasing role for imaging in the pulmonary hypertension clinic. This will reduce the need for invasive investigations, whilst providing valuable insights that will improve our understanding of disease facilitate a more targeted approach to treatment.
Collapse
Affiliation(s)
| | - Jim M Wild
- a Academic Radiology , The University of Sheffield , Sheffield , UK
| | - Smitha Rajaram
- b Sheffield Pulmonary Vascular Disease Unit , Sheffield Teaching Hospitals , Sheffield , UK
| | - Andy J Swift
- a Academic Radiology , The University of Sheffield , Sheffield , UK
| | - David G Kiely
- b Sheffield Pulmonary Vascular Disease Unit , Sheffield Teaching Hospitals , Sheffield , UK
| |
Collapse
|
42
|
Optimizing Cardiac CTA Acquisition in Congenital Heart Disease. CURRENT RADIOLOGY REPORTS 2018. [DOI: 10.1007/s40134-018-0294-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
43
|
Chin M, Johns C, Currie BJ, Weatherley N, Hill C, Elliot C, Rajaram S, Wild JM, Condliffe R, Bianchi S, Kiely DG, Swift AJ. Pulmonary Artery Size in Interstitial Lung Disease and Pulmonary Hypertension: Association with Interstitial Lung Disease Severity and Diagnostic Utility. Front Cardiovasc Med 2018; 5:53. [PMID: 29938208 PMCID: PMC6003274 DOI: 10.3389/fcvm.2018.00053] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/09/2018] [Indexed: 11/13/2022] Open
Abstract
Purpose It is postulated that ILD causes PA dilatation independent of the presence of pulmonary hypertension (PH), so the use of PA size to screen for PH is not recommended. The aims of this study were to investigate the association of PA size with the presence and severity of ILD and to assess the diagnostic accuracy of PA size for detecting PH. Methods Incident patients referred to a tertiary PH centre underwent baseline thoracic CT, MRI and right heart catheterisation (RHC). Pulmonary artery diameter was measured on CT pulmonary angiography and pulmonary arterial areas on MRI. A thoracic radiologist scored the severity of ILD on CT from 0 to 4, 0 = absent, 1 = 1–25%, 2 = 26–50%, 3 = 51–75%, and 4 = 76–100% extent of involvement. Receiver operating characteristic analysis and linear regression were employed to assess diagnostic accuracy and independent associations of PA size. Results 110 had suspected PH due to ILD (age 65 years (SD 13), M:F 37:73) and 379 had suspected PH without ILD (age 64 years (SD 13), M:F 161:218). CT derived main PA diameter was accurate for detection of PH in patients both with and without ILD - AUC 0.873, p =< 0.001, and AUC 0.835, p =< 0.001, respectively, as was MRI diastolic PA area, AUC 0.897, p =< 0.001, and AUC 0.857, p =< 0.001, respectively Significant correlations were identified between mean pulmonary arterial pressure (mPAP) and PA diameter in ILD (r = 0.608, p < 0.001), and non-ILD cohort (r = 0.426, p < 0.001). PA size was independently associated with mPAP (p < 0.001) and BSA (p = 0.001), but not with forced vital capacity % predicted (p = 0.597), Transfer factor of the lungs for carbon monoxide (TLCO) % predicted (p = 0.321) or the presence of ILD on CT (p = 0.905). The severity of ILD was not associated with pulmonary artery dilatation (r = 0.071, p = 0.459). Conclusions Pulmonary arterial pressure elevation leads to pulmonary arterial dilation, which is not independently influenced by the presence or severity of ILD measured by FVC, TLCO, or disease severity on CT. Pulmonary arterial diameter has diagnostic value in patients with or without ILD and suspected PH.
Collapse
Affiliation(s)
- Matthew Chin
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Christopher Johns
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Benjamin J Currie
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Nicholas Weatherley
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Catherine Hill
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Charlie Elliot
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Smitha Rajaram
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Jim M Wild
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
| | - Robin Condliffe
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Stephen Bianchi
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - David G Kiely
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Andrew J Swift
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom.,Institute for in silico Medicine, Sheffield, United Kingdom
| |
Collapse
|
44
|
Abstract
PURPOSE OF REVIEW Pulmonary vascular disease (PVD) complicates the course of many cardiovascular, pulmonary and other systemic diseases in children. The physiological sequelae (pulmonary hypertension and elevated pulmonary vascular resistance) can overwhelm the right ventricle and lead to circulatory collapse. Despite the common end-point, the preceding pathophysiology is complex and variable and requires a tailored approach to diagnosis and management. In this article, we will review the most recent evidence and explore an approach to current controversies in the diagnosis and management of common or challenging patient subgroups. RECENT FINDINGS New methods of interpreting data derived from echocardiography and cardiac magnetic resonance imaging may assist in risk stratification and response to therapy. In specific patient subgroups, standard pharmacological therapies to reduce right ventricle afterload may be overutilized, ineffective and in some cases harmful. In the patient failing pharmacological therapy, new and novel techniques are being explored including temporary extracorporeal mechanical circulatory support, pumpless lung assist devices and novel surgical and catheterization procedures. SUMMARY PVD is a diverse entity, and attention to the underlying pathophysiology is essential for appropriate management. Despite significant advances in our understanding, the majority of data comes from small uncontrolled studies and must be interpreted with caution.
Collapse
|
45
|
Currie BJ, Johns C, Chin M, Charalampopolous T, Elliot CA, Garg P, Rajaram S, Hill C, Wild JW, Condliffe RA, Kiely DG, Swift AJ. CT derived left atrial size identifies left heart disease in suspected pulmonary hypertension: Derivation and validation of predictive thresholds. Int J Cardiol 2018. [PMID: 29530618 PMCID: PMC5899969 DOI: 10.1016/j.ijcard.2018.02.114] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background Patients with pulmonary hypertension due to left heart disease (PH-LHD) have overlapping clinical features with pulmonary arterial hypertension making diagnosis reliant on right heart catheterization (RHC). This study aimed to investigate computed tomography pulmonary angiography (CTPA) derived cardiopulmonary structural metrics, in comparison to magnetic resonance imaging (MRI) for the diagnosis of left heart disease in patients with suspected pulmonary hypertension. Methods Patients with suspected pulmonary hypertension who underwent CTPA, MRI and RHC were identified. Measurements of the cardiac chambers and vessels were recorded from CTPA and MRI. The diagnostic thresholds of individual measurements to detect elevated pulmonary arterial wedge pressure (PAWP) were identified in a derivation cohort (n = 235). Individual CT and MRI derived metrics were tested in validation cohort (n = 211). Results 446 patients, of which 88 had left heart disease. Left atrial area was a strong predictor of elevated PAWP>15 mm Hg and PAWP>18 mm Hg, area under curve (AUC) 0.854, and AUC 0.873 respectively. Similar accuracy was also identified for MRI derived LA volume, AUC 0.852 and AUC 0.878 for PAWP > 15 and 18 mm Hg, respectively. Left atrial area of 26.8 cm2 and 30.0 cm2 were optimal specific thresholds for identification of PAWP > 15 and 18 mm Hg, had sensitivity of 60%/53% and specificity 89%/94%, respectively in a validation cohort. Conclusions CTPA and MRI derived left atrial size identifies left heart disease in suspected pulmonary hypertension with high specificity. The proposed diagnostic thresholds for elevated left atrial area on routine CTPA may be a useful to indicate the diagnosis of left heart disease in suspected pulmonary hypertension. Routine CTPA can diagnose left heart disease in suspected pulmonary hypertension. Complex multiparameter models do not improve LHD diagnosis. Highly specific thresholds have been derived and validated.
Collapse
Affiliation(s)
- Benjamin J Currie
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Chris Johns
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Matthew Chin
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | | | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - Pankaj Garg
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Smitha Rajaram
- Radiology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Catherine Hill
- Radiology Department, Royal Hallamshire Hospital, Sheffield, UK
| | - Jim W Wild
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK
| | - Robin A Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK
| | - Andy J Swift
- Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK; INSIGNEO, Institute for in silico medicine, University of Sheffield, UK.
| |
Collapse
|
46
|
Granzyme B deficiency promotes osteoblastic differentiation and calcification of vascular smooth muscle cells in hypoxic pulmonary hypertension. Cell Death Dis 2018; 9:221. [PMID: 29445095 PMCID: PMC5833422 DOI: 10.1038/s41419-018-0315-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Revised: 12/28/2017] [Accepted: 01/04/2018] [Indexed: 02/08/2023]
Abstract
Calcification is a major risk factor for vascular integrity. This pathological symptom and the underlying mechanisms in hypoxic pulmonary artery hypertension remain elusive. Here we report that pulmonary vascular medial calcification is elevated in pulmonary artery hypertension models as a result of an osteoblastic phenotype change of pulmonary arterial smooth muscle cells induced by hypoxia. Notably, inhibiting store-operated calcium channels significantly decreased osteoblastic differentiation and calcification of pulmonary arterial smooth muscle cells under hypoxia. We identified granzyme B, a major constituent of cytotoxic T lymphocytes/natural killer cell granules involved in apoptosis, as the main regulator of pulmonary arterial calcification. Overexpression of granzyme B blocked the mineralization through its effect on store-operated calcium channels in cultured pulmonary arterial smooth muscle cells under hypoxic conditions. Mice with overexpression of granzyme B exposed to hypoxia for 3 weeks showed attenuated vascular calcification and pathological progression of hypoxic pulmonary arterial hypertension. Our findings emphasize the central function of granzyme B in coordinating vascular calcification in hypoxic pulmonary arterial hypertension.
Collapse
|
47
|
Hadinnapola C, Bleda M, Haimel M, Screaton N, Swift A, Dorfmüller P, Preston SD, Southwood M, Hernandez-Sanchez J, Martin J, Treacy C, Yates K, Bogaard H, Church C, Coghlan G, Condliffe R, Corris PA, Gibbs S, Girerd B, Holden S, Humbert M, Kiely DG, Lawrie A, Machado R, MacKenzie Ross R, Moledina S, Montani D, Newnham M, Peacock A, Pepke-Zaba J, Rayner-Matthews P, Shamardina O, Soubrier F, Southgate L, Suntharalingam J, Toshner M, Trembath R, Vonk Noordegraaf A, Wilkins MR, Wort SJ, Wharton J, Gräf S, Morrell NW. Phenotypic Characterization of EIF2AK4 Mutation Carriers in a Large Cohort of Patients Diagnosed Clinically With Pulmonary Arterial Hypertension. Circulation 2017; 136:2022-2033. [PMID: 28972005 DOI: 10.1161/circulationaha.117.028351] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 08/25/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is a rare disease with an emerging genetic basis. Heterozygous mutations in the gene encoding the bone morphogenetic protein receptor type 2 (BMPR2) are the commonest genetic cause of PAH, whereas biallelic mutations in the eukaryotic translation initiation factor 2 alpha kinase 4 gene (EIF2AK4) are described in pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Here, we determine the frequency of these mutations and define the genotype-phenotype characteristics in a large cohort of patients diagnosed clinically with PAH. METHODS Whole-genome sequencing was performed on DNA from patients with idiopathic and heritable PAH and with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis recruited to the National Institute of Health Research BioResource-Rare Diseases study. Heterozygous variants in BMPR2 and biallelic EIF2AK4 variants with a minor allele frequency of <1:10 000 in control data sets and predicted to be deleterious (by combined annotation-dependent depletion, PolyPhen-2, and sorting intolerant from tolerant predictions) were identified as potentially causal. Phenotype data from the time of diagnosis were also captured. RESULTS Eight hundred sixty-four patients with idiopathic or heritable PAH and 16 with pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis were recruited. Mutations in BMPR2 were identified in 130 patients (14.8%). Biallelic mutations in EIF2AK4 were identified in 5 patients with a clinical diagnosis of pulmonary veno-occlusive disease/pulmonary capillary hemangiomatosis. Furthermore, 9 patients with a clinical diagnosis of PAH carried biallelic EIF2AK4 mutations. These patients had a reduced transfer coefficient for carbon monoxide (Kco; 33% [interquartile range, 30%-35%] predicted) and younger age at diagnosis (29 years; interquartile range, 23-38 years) and more interlobular septal thickening and mediastinal lymphadenopathy on computed tomography of the chest compared with patients with PAH without EIF2AK4 mutations. However, radiological assessment alone could not accurately identify biallelic EIF2AK4 mutation carriers. Patients with PAH with biallelic EIF2AK4 mutations had a shorter survival. CONCLUSIONS Biallelic EIF2AK4 mutations are found in patients classified clinically as having idiopathic and heritable PAH. These patients cannot be identified reliably by computed tomography, but a low Kco and a young age at diagnosis suggests the underlying molecular diagnosis. Genetic testing can identify these misclassified patients, allowing appropriate management and early referral for lung transplantation.
Collapse
Affiliation(s)
- Charaka Hadinnapola
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.)
| | - Marta Bleda
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.)
| | - Matthias Haimel
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.).,NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.)
| | - Nicholas Screaton
- Papworth Hospital, Cambridge, UK (N.S., S.D.P., M.S., J.H.-S., J.P.-Z., M.T.)
| | | | | | - Stephen D Preston
- Papworth Hospital, Cambridge, UK (N.S., S.D.P., M.S., J.H.-S., J.P.-Z., M.T.)
| | - Mark Southwood
- Papworth Hospital, Cambridge, UK (N.S., S.D.P., M.S., J.H.-S., J.P.-Z., M.T.)
| | | | - Jennifer Martin
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.).,NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.)
| | - Carmen Treacy
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.)
| | - Katherine Yates
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.).,NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.)
| | - Harm Bogaard
- VU University Medical Centre, Amsterdam, the Netherlands (H.B., A.V.N.)
| | - Colin Church
- Golden Jubilee Hospital, Glasgow, UK (C.C., A.P.)
| | | | | | | | - Simon Gibbs
- Imperial College London, UK (S. Gibbs, M.R.W., J.W.)
| | | | | | - Marc Humbert
- Université Paris-Sud, France (P.D., B.G., M.H., D.M.)
| | - David G Kiely
- Royal Hallamshire Hospital, Sheffield, UK (R.C., D.G.K.)
| | | | | | | | | | - David Montani
- Université Paris-Sud, France (P.D., B.G., M.H., D.M.)
| | - Michael Newnham
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.)
| | | | - Joanna Pepke-Zaba
- Papworth Hospital, Cambridge, UK (N.S., S.D.P., M.S., J.H.-S., J.P.-Z., M.T.)
| | | | - Olga Shamardina
- NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.)
| | | | - Laura Southgate
- King's College London, UK (L.S., R.T.).,St George's, University of London, UK (L.S.)
| | | | - Mark Toshner
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.).,Papworth Hospital, Cambridge, UK (N.S., S.D.P., M.S., J.H.-S., J.P.-Z., M.T.)
| | | | | | | | | | - John Wharton
- Imperial College London, UK (S. Gibbs, M.R.W., J.W.)
| | | | - Stefan Gräf
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.).,NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.).,Department of Haematology, University of Cambridge, UK (S. Gräf)
| | - Nicholas W Morrell
- Department of Medicine, University of Cambridge, UK (C.H., M.B., M.H., J.M., C.T., K.Y., M.N., M.T., S. Gräf, N.W.M.) .,NIHR BioResource-Rare Diseases (M.H., J.M., K.Y., P.R.-M., O.S., S. Gräf, N.W.M.)
| |
Collapse
|
48
|
Connolly MJ, Abdullah S, Ridout DA, Schreiber BE, Haddock JA, Coghlan JG. Prognostic significance of computed tomography criteria for pulmonary veno-occlusive disease in systemic sclerosis-pulmonary arterial hypertension. Rheumatology (Oxford) 2017; 56:2197-2203. [DOI: 10.1093/rheumatology/kex351] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Indexed: 11/12/2022] Open
|
49
|
|
50
|
Kammerlander AA, Aschauer S, Zotter-Tufaro C, Duca F, Knechtelsdorfer K, Wiesinger M, Schwaiger ML, Dalos D, Schneider M, Marzluf BA, Bonderman D, Mascherbauer J. Diameter of the Pulmonary Artery in Relation to the Ascending Aorta: Association with Cardiovascular Outcome. Radiology 2017; 284:685-693. [PMID: 28562205 DOI: 10.1148/radiol.2017161849] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Purpose To investigate whether the pulmonary artery (PA)-to-ascending aorta (Ao) ratio is associated with outcome in unselected patients referred for cardiac magnetic resonance (MR) imaging. Materials and Methods This study prospectively enrolled 650 consecutive patients (47.2% women; mean age, 56.1 years ± 17.7 [standard deviation]). Diameters of PA and Ao were measured in axial black blood images. On the basis of previous results, a PA-to-Ao ratio of 1.0 or greater was chosen as the cutoff for further analysis. Univariable and multivariable Cox regression models were used to investigate the primary end point, which was defined as a composite of cardiovascular hospitalization and death. Results A PA-to-Ao ratio of 1.0 or greater was present in 131 (20.2%) patients. Patients with a PA-to-Ao ratio of 1.0 or greater were predominantly women (P = .010); more frequently presented with atrial fibrillation (P < .001), diabetes (P < .001), and impaired renal function (P < .001); and had higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels (P < .001), larger left (P = .023) and right ventricles (RV; P = .002), and worse RV function (P < .001). Patients were followed for 17.8 months ± 12.9, during which 110 patients (16.9%) reached the primary end point. By Kaplan-Meier analysis, event-free survival was significantly worse in patients with a PA-to-Ao ratio of 1.0 or greater (log-rank test, P < .001). A PA-to-Ao ratio of 1.0 or greater was independently associated with outcome by multivariable Cox regression analysis, in addition to age, NT-proBNP serum levels, and RV size. Conclusion A PA-to-Ao ratio of 1.0 or greater identified patients at risk, most likely because of elevated PA pressures. On the basis of these results, the PA-to-Ao ratio should routinely be reported at cardiac MR imaging. © RSNA, 2017 Online supplemental material is available for this article.
Collapse
Affiliation(s)
- Andreas A Kammerlander
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Stefan Aschauer
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Caroline Zotter-Tufaro
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Franz Duca
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Klaus Knechtelsdorfer
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Matthias Wiesinger
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Marianne L Schwaiger
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Daniel Dalos
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Matthias Schneider
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Beatrice A Marzluf
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Diana Bonderman
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| | - Julia Mascherbauer
- From the Department of Cardiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria (A.A.K., S.A., C.Z.T., F.D., K.K., M.W., M.L.S., D.D., M.S., D.B., J.M.) and Department of Thoracic Surgery, Otto Wagner Hospital, Vienna, Austria (B.A.M.)
| |
Collapse
|