1
|
Delcroix M, de Perrot M, Jaïs X, Jenkins DP, Lang IM, Matsubara H, Meijboom LJ, Quarck R, Simonneau G, Wiedenroth CB, Kim NH. Chronic thromboembolic pulmonary hypertension: realising the potential of multimodal management. THE LANCET. RESPIRATORY MEDICINE 2023; 11:836-850. [PMID: 37591299 DOI: 10.1016/s2213-2600(23)00292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/13/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. Important advances have enabled better understanding, characterisation, and treatment of this condition. Guidelines recommending systematic follow-up after acute pulmonary embolism, and the insight that CTEPH can mimic acute pulmonary embolism on initial presentation, have led to the definition of CTEPH imaging characteristics, the introduction of artificial intelligence diagnosis pathways, and thus the prospect of easier and earlier CTEPH diagnosis. In this Series paper, we show how the understanding of CTEPH as a sequela of inflammatory thrombosis has driven successful multidisciplinary management that integrates surgical, interventional, and medical treatments. We provide imaging examples of classical major vessel targets, describe microvascular targets, define available tools, and depict an algorithm facilitating the initial treatment strategy in people with newly diagnosed CTEPH based on a multidisciplinary team discussion at a CTEPH centre. Further work is needed to optimise the use and combination of multimodal therapeutic options in CTEPH to improve long-term outcomes for patients.
Collapse
Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium.
| | - Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, ON, Canada
| | - Xavier Jaïs
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - David P Jenkins
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Division of Cardiology, Department of Internal Medicine II, Vienna General Hospital, Centre for CardioVascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Rozenn Quarck
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven-University of Leuven, Leuven, Belgium
| | - Gérald Simonneau
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Pneumologie, Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | - Nick H Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, University of California San Diego, La Jolla, CA, USA
| |
Collapse
|
2
|
El Embaby DAES. Assessment of pulmonary hypertension by cardiac MRI and right sided heart catheter in COPD patients. JOURNAL OF LUNG, PULMONARY & RESPIRATORY RESEARCH 2023; 10:5-9. [DOI: 10.15406/jlprr.2023.10.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
Background: Pulmonary hypertension (PH) is a progressive disorder characterized by abnormally elevated blood pressure of the pulmonary circulation which results, over time, from extensive vascular remodeling and increased pulmonary vascular resistance (PVR). Recent advances in cMRI technology have led to the development of techniques for noninvasive assessment of the morphology of the right side of the heart to be correlated to the hemodynamic parameters collected by RHC which is still the golden standard technique of PH diagnosis. Aim: To assess the role of Cardiac MRI in severe COPD patients with pulmonary artery pressure more than 35 mmHg as evaluated by Echocardiography and right sided cardiac catheterization. Patients and methods: The current study was conducted upon 20 patients with moderate or severe chronic obstructive pulmonary disease (COPD) by spirometry according to GOLD 2022 criteria who had been assessed for severe pulmonary hypertension with Pulmonary Artery Pressure more than 35 mmHg by cardiac Magnetic resonance imaging (cMRI) and right sided heart catheter (RHC). They were recruited from the outpatient clinic and department of chest specialized hospital Kobry Elkobba Armed Forces. Results: Twenty patients included in the study were 90% males, mean age about 64.50 ± 7.94 years old with mean smoking duration 33.89 ±7.03 years and 45% with co-morbidities. Spirometry done for all studied cases included FEV1/FVC, FEV1 and FVC parameters with mean range 43.40 ± 5.17, 38.90 ± 8.60, 79.45 ± 16.59 respectively. The descriptive data of HRCT showed 60% of the patients with emphysema while the rest showed mixed emphysema and ILD. V/Q scan study was positive in 4 patients which represented 20% of the patients whose all included in group B (mPA > 43.5 mmHg). All studied COPD patients who showed severe PHT by a measurement of mPAP > 35 mmHg by RHC with normal PCW pressure underwent cMRI study to assess right ventricular structure and morphology. Conclusion: Cardiac MRI showed a great rule in the evaluation of the morphological changes associated with the condition of COPDPH in the right side of the heart which should affect its functions. The cardiac MRI is not the best tool in assessment of the right side of the heart in COPD patients due to many causes like the difficulty of holding breaths with COPDPH patients during the maneuver to snap accurate clear shots of the heart, the hypoxia in those patients which makes the maneuver more difficult, the associated co-morbidities may interfere with completing the maneuver like the chronic kidney disease that prohibit the use of gadolinium dye and other co-morbidities like morbid obesity that will not allow the patient to get through the MRI
Collapse
|
3
|
Naeije R, Richter MJ, Rubin LJ. The physiologic basis of pulmonary arterial hypertension. Eur Respir J 2021; 59:13993003.02334-2021. [PMID: 34737219 PMCID: PMC9203839 DOI: 10.1183/13993003.02334-2021] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/18/2021] [Indexed: 11/05/2022]
Abstract
Pulmonary arterial hypertension (PAH) is a rare dyspnea-fatigue syndrome caused by a progressive increase in pulmonary vascular resistance (PVR) and eventual right ventricular (RV) failure. In spite of extensive pulmonary vascular remodeling, lung function in PAH is generally well preserved, with hyperventilation and increased physiologic dead space, but minimal changes in lung mechanics and only mild to moderate hypoxemia and hypocapnia. Hypoxemia is mainly caused by a low mixed venous PO2 from a decreased cardiac output. Hypocapnia is mainly caused by an increased chemosensitivity. Exercise limitation in PAH is cardiovascular rather than ventilatory or muscular. The extent of pulmonary vascular disease in PAH is defined by multipoint pulmonary vascular pressure-flow relationships with a correction for hematocrit. Pulsatile pulmonary vascular pressure-flow relationships in PAH allow for the assessment of RV hydraulic load. This analysis is possible either in the frequency-domain or in the time-domain. The RV in PAH adapts to increased afterload by an increased contractility to preserve its coupling to the pulmonary circulation. When this homeometric mechanism is exhausted, the RV dilates to preserve flow output by an additional heterometric mechanism. Right heart failure is then diagnosed by imaging of increased right heart dimensions and clinical systemic congestion signs and symptoms. The coupling of the RV to the pulmonary circulation is assessed by the ratio of end-systolic to arterial elastances, but these measurements are difficult. Simplified estimates of RV-PA coupling can be obtained by magnetic resonance or echocardiographic imaging of ejection fraction.
Collapse
Affiliation(s)
| | - Manuel J Richter
- Department of Internal Medicine, Justus Liebig-University, Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Lewis J Rubin
- University of California, San Diego, La Jolla, CA, USA
| |
Collapse
|
4
|
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: 249] [Impact Index Per Article: 83.0] [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
|
5
|
Abstract
PURPOSE OF REVIEW The present review provides an update on treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a rare form of pulmonary hypertension characterized by precapillary pulmonary hemodynamic parameters with chronic thrombotic occlusion of the pulmonary vasculature. RECENT FINDINGS Pulmonary thromboendarectomy (PTE) remains the recommended treatment for patients with surgically accessible disease. Recent data suggest that patients preoperatively bridged with medical therapy may have improved outcomes but further research is needed. Riociguat improves hemodynamics, right ventricular function, quality of life, and functional capacity and is the drug of choice for patients with inoperable/persistent disease. Recently published data suggest that endothelin receptor blockers and treprostinil may also have a role in medical management of this patient population. A growing body of evidence indicates that in experienced centers balloon pulmonary angioplasty (BPA) may be a well tolerated and effective adjunct to pharmacological treatment for patients with inoperable disease affecting subsegmental vasculature. SUMMARY Untreated CTEPH carries significant morbidity and mortality. Recent publications provide a wealth of data on safety and efficacy of BPA for inoperable subsegmental disease, but its precise fit in the treatment algorithm, both pharmacological and procedural, requires further investigation. PTE remains the procedure of choice for surgically accessible disease.
Collapse
|
6
|
Abstract
The treatment of chronic thromboembolic pulmonary hypertension has expanded considerably. The ability to endarterectomize chronic thromboembolic material, the availability of pulmonary hypertension medical therapy to treat inoperable chronic thromboembolic pulmonary hypertension and/or residual pulmonary hypertension, and the rebirth of pulmonary balloon angioplasty have changed the management landscape. Patient selection requires a multidisciplinary evaluation at an experienced center. What is inoperable chronic thromboembolic pulmonary hypertension to one group may be operable chronic thromboembolic pulmonary hypertension to another. The ultimate challenge then becomes which intervention provides the optimal long-term outcome for any individual patient.
Collapse
Affiliation(s)
- William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140, USA.
| |
Collapse
|
7
|
Gerges C, Gerges M, Friewald R, Fesler P, Dorfmüller P, Sharma S, Karlocai K, Skoro-Sajer N, Jakowitsch J, Moser B, Taghavi S, Klepetko W, Lang IM. Microvascular Disease in Chronic Thromboembolic Pulmonary Hypertension. Circulation 2020; 141:376-386. [DOI: 10.1161/circulationaha.119.041515] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Pulmonary endarterectomy (PEA) is the gold standard treatment for patients with operable chronic thromboembolic pulmonary hypertension. However, persistent pulmonary hypertension (PH) after PEA remains a major determinant of poor prognosis. A concomitant small-vessel arteriopathy in addition to major pulmonary artery obstruction has been suggested to play an important role in the development of persistent PH and survival after PEA. One of the greatest unmet needs in the current preoperative evaluation is to assess the presence and severity of small-vessel arteriopathy. Using the pulmonary artery occlusion technique, we sought to assess the presence and degree of small-vessel disease in patients with chronic thromboembolic pulmonary hypertension undergoing PEA to predict postoperative outcome before surgery.
Methods:
Based on pulmonary artery occlusion waveforms yielding an estimate of the effective capillary pressure, we partitioned pulmonary vascular resistance in larger arterial (upstream resistance [R
up
]) and small arterial plus venous components (downstream resistance) in 90 patients before PEA. For validation, lung wedge biopsies were taken from nonobstructed and obstructed lung territories during PEA in 49 cases. Biopsy sites were chosen according to the pulmonary angiogram still frames that were mounted in the operating room. All vessels per specimen were measured in each patient. Percent media (%MT; arteries) and intima thickness (%IT; arteries, veins, and indeterminate vessels) were calculated relative to external vessel diameter.
Results:
Decreased R
up
was an independent predictor of persistent PH (odds ratio per 10%, 0.40 [95% CI, 0.23–0.69];
P
=0.001) and survival (hazard ratio per 10%, 0.03 [95% CI, 0.00–0.33];
p
=0.004). Arterial %MT and %IT of nonobstructed lung territories and venous %IT of obstructed lung territories were significantly increased in patients with persistent PH and nonsurvivors. R
up
correlated inversely with %MT (
r
=–0.72,
P
<0.001) and %IT (
r
=–0.62,
P
<0.001) of arteries from nonobstructed lung territories and with %IT (
r
=–0.44,
P
=0.024) of veins from obstructed lung territories. Receiver operating characteristic analysis disclosed that R
up
<66% predicted persistent PH after PEA, whereas R
up
<60% identified patients with poor prognosis after PEA.
Conclusions:
Pulmonary artery occlusion waveform analysis with estimation of R
up
seems to be a valuable technique for assessing the degree of small-vessel disease and postoperative outcome after PEA in chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Mario Gerges
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Richard Friewald
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Pierre Fesler
- PhyMedExp, University of Montpellier, CNRS, INSERM, and Department of Internal Medicine Lapeyronie, University Hospital of Montpellier, France (P.F.)
| | - Peter Dorfmüller
- Department of Pathology, University Hospital of Giessen and Marburg (UKGM), Germany (P.D.)
| | - Smriti Sharma
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | - Kristof Karlocai
- Department of Pulmonology, Semmelweis University, Budapest, Hungary (K.K.)
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| | | | - Bernhard Moser
- Department of Thoracic Surgery, Division of Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Shahrokh Taghavi
- Department of Thoracic Surgery, Division of Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Walter Klepetko
- Department of Thoracic Surgery, Division of Surgery (B.M., S.T., W.K.), Medical University of Vienna, Austria
| | - Irene M. Lang
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital (C.G., M.G., R.F., S.S. N.S.-S., I.M.L.), Medical University of Vienna, Austria
| |
Collapse
|
8
|
Gerges C, Gerges M, Fesler P, Pistritto AM, Konowitz NP, Jakowitsch J, Celermajer DS, Lang I. In-depth haemodynamic phenotyping of pulmonary hypertension due to left heart disease. Eur Respir J 2018; 51:13993003.00067-2018. [DOI: 10.1183/13993003.00067-2018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/10/2018] [Indexed: 12/22/2022]
Abstract
The commonest cause of pulmonary hypertension (PH) is left heart disease (LHD). The current classification system for definitions of PH-LHD is under review. We therefore performed prospective in-depth invasive haemodynamic phenotyping in order to assess the site of increased pulmonary vascular resistance (PVR) in PH-LHD subsets.Based on pulmonary artery occlusion waveforms yielding an estimate of the effective capillary pressure, we partitioned PVR in larger arterial (Rup, upstream resistance) and small arterial plus venous components (Rds, downstream resistance). In the case of small vessel disease, Rup decreases and Rds increases. Inhaled nitric oxide (NO) testing was used to assess acute vasoreactivity.Right ventricular afterload (PVR, pulmonary arterial compliance and effective arterial elastance) was significantly higher in combined post- and pre-capillary PH (Cpc-PH, n=35) than in isolated post-capillary PH (Ipc-PH, n=20). Right ventricular afterload decreased during inhalation of NO in Cpc-PH and idiopathic pulmonary arterial hypertension (n=31), but remained unchanged in Ipc-PH. Rup was similar in Cpc-PH (66.8±10.8%) and idiopathic pulmonary arterial hypertension (65.0±12.2%; p=0.530) suggesting small vessel disease, but significantly higher in Ipc-PH (96.5±4.5%; p<0.001) suggesting upstream transmission of elevated left atrial pressure.Right ventricular afterload is driven by elevated left atrial pressure in Ipc-PH and is further increased by elevated small vessel resistance in Cpc-PH. Cpc-PH is responsive to inhaled NO. Our data support current definitions of PH-LHD subsets.
Collapse
|
9
|
Suda R, Tanabe N, Ishida K, Kato F, Urushibara T, Sekine A, Nishimura R, Jujo T, Sugiura T, Shigeta A, Sakao S, Tatsumi K. Prognostic and pathophysiological marker for patients with chronic thromboembolic pulmonary hypertension: Usefulness of diffusing capacity for carbon monoxide at diagnosis. Respirology 2016; 22:179-186. [DOI: 10.1111/resp.12883] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 05/06/2016] [Accepted: 06/13/2016] [Indexed: 12/15/2022]
Affiliation(s)
- Rika Suda
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Nobuhiro Tanabe
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Fumiaki Kato
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Takashi Urushibara
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Ayumi Sekine
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Rintaro Nishimura
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Takayuki Jujo
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Toshihiko Sugiura
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Ayako Shigeta
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine; Chiba University; Chiba Japan
| |
Collapse
|
10
|
Guth S, Wiedenroth CB, Kramm T, Mayer E. Pulmonary endarterectomy for the treatment of chronic thromboembolic pulmonary hypertension. Expert Rev Respir Med 2016; 10:673-84. [PMID: 27070482 DOI: 10.1080/17476348.2016.1176915] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Pulmonary endarterectomy is a curative treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). There is a growing body of evidence suggesting that not only patients with CTEPH but also patients with pulmonary arterial obstructions and mean pulmonary artery pressures < 25 mmHg should be offered surgery. In this review, the recent literature regarding pathophysiology, diagnostic methods, decision making by an expert CTEPH team, and surgical techniques will be summarized. Novel alternative treatment options for inoperable CTEPH patients will be discussed, i.e. targeted medical therapy and balloon pulmonary angioplasty. For the future the major task will be to define a clear selection process for the optimal treatment of the individual CTEPH patient.
Collapse
Affiliation(s)
- Stefan Guth
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Christoph B Wiedenroth
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Thorsten Kramm
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| | - Eckhard Mayer
- a Department of Thoracic Surgery , Kerckhoff Heart and Lung Center , Bad Nauheim , Germany
| |
Collapse
|
11
|
Jujo T, Sakao S, Ishibashi-Ueda H, Ishida K, Naito A, Sugiura T, Shigeta A, Tanabe N, Masuda M, Tatsumi K. Evaluation of the Microcirculation in Chronic Thromboembolic Pulmonary Hypertension Patients: The Impact of Pulmonary Arterial Remodeling on Postoperative and Follow-Up Pulmonary Arterial Pressure and Vascular Resistance. PLoS One 2015; 10:e0133167. [PMID: 26252755 PMCID: PMC4529247 DOI: 10.1371/journal.pone.0133167] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 06/24/2015] [Indexed: 11/22/2022] Open
Abstract
Background Chronic thromboembolic pulmonary hypertension (CTEPH) is generally recognized to be caused by persistent organized thrombi that occlude the pulmonary arteries. The aim of this study was to investigate the characteristics of small vessel remodeling and its impact on the hemodynamics in CTEPH patients. Methods and Results Hemodynamic data were obtained from right heart catheterization in 17 CTEPH patients before pulmonary endarterectomy (PEA). Lung tissue specimens were obtained at the time of PEA. Pathological observations and evaluation of quantitative changes in pulmonary muscular arteries and veins were performed using light microscopy on 423 slides in 17 patients. The relationship between the results and the hemodynamics of CTEPH was investigated. Pulmonary arteriopathy and venopathy were recognized in most cases, although no plexiform lesions and no capillary-hemangiomatosis-like lesions were detected in any of the specimens. The severity of pulmonary arteriopathy was correlated with pulmonary vascular resistance (PVR) in the postoperative and follow-up periods. The PVR and mean pulmonary arterial pressure were significantly higher in the high-obstruction group than in the low-obstruction group. The findings in pulmonary venopathy were similar to the findings seen in pulmonary veno-occlusive disease in some cases, although severe venopathy was only observed in a portion of the pulmonary veins. There was a significant correlation between the extent of pulmonary arteriopathy and venopathy, although an effect of pulmonary venopathy to hemodynamics, including pulmonary arterial wedged pressure (PAWP), could not be identified. Conclusion The vascular remodeling of the pulmonary muscular arteries was closely associated with the hemodynamics of CTEPH. Severe pulmonary arteriopathy might be related to residual pulmonary hypertension after PEA. Those altered pulmonary arteries might be a new target for the persistent PH after the operation.
Collapse
Affiliation(s)
- Takayuki Jujo
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260–8670, Japan
- * E-mail:
| | - Seiichiro Sakao
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Hatsue Ishibashi-Ueda
- Department of Pathology, National Cerebral and Cardiovascular Center, 5-7-1, Fujishiro-Dai, Suita City, Osaka, 565–8565, Japan
| | - Keiichi Ishida
- Department of Cardiovascular Surgery, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Akira Naito
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Toshihiko Sugiura
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Ayako Shigeta
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Nobuhiro Tanabe
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
- Department of Advanced Medicine in Pulmonary Hypertension, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| | - Masahisa Masuda
- Department of Cardiovascular Surgery, Chiba Medical Center, National Hospital Organization, 4-1-2, Tsubakimori, Chuo-ku, Chiba, 260–8606, Japan
| | - Koichiro Tatsumi
- Department of Respirology (B2), Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-Ku, Chiba, 260–8670, Japan
| |
Collapse
|
12
|
Gerges C, Skoro-Sajer N, Lang IM. Right ventricle in acute and chronic pulmonary embolism (2013 Grover Conference series). Pulm Circ 2015; 4:378-86. [PMID: 25621151 DOI: 10.1086/676748] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 02/27/2014] [Indexed: 02/02/2023] Open
Abstract
Venous thromboembolism (VTE) encompasses deep-vein thrombosis and pulmonary embolism (PE). It is the third-most-frequent cardiovascular disease, with an overall annual incidence of 1-2 per 1,000 population. Chronic thromboembolic pulmonary hypertension (CTEPH) is regarded as a late sequela of PE, with a reported incidence varying between 0.1% and 9.1% of those surviving acute VTE. Right ventricular (RV) function is dependent on afterload. The most precise technique to describe RV function is invasive assessment of the RV-to-pulmonary vascular coupling. However, assessments of RV afterload (i.e., steady and pulsatile flow components and their product, the RC-time) may be useful hemodynamic surrogates of coupling. RV load is different in acute and chronic PE. In acute PE, more than 60% occlusion of the cross-sectional area of the pulmonary artery within a short period of time leads to abrupt hemodynamic collapse. If the time of occlusion is limited to ∼15 seconds, significant decreases in fractional area change, tricuspid annulus systolic excursion, and RV free-wall deformation (strain) occur, with the latter showing significant postsystolic shortening. These changes have similarities to ischemic stunning, and they recover within minutes. In CTEPH, studies of pulmonary vascular resistance (PVR) and pulmonary arterial compliance demonstrated low RC-times that were further lowered after pulmonary endarterectomy (PEA). Immediate postoperative PVR was the only predictor of long-term survival/freedom from lung transplantation, suggesting that the effect of PEA on opening vascular territories to flow outweighs its effect on proximal stiffness. This review summarizes the current knowledge on vascular and intrinsic RV adaptation to VTE, including CTEPH, and the role of imaging.
Collapse
Affiliation(s)
- Christian Gerges
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
13
|
D'Armini AM, Morsolini M, Mattiucci G, Grazioli V, Pin M, Valentini A, Silvaggio G, Klersy C, Dore R. Pulmonary endarterectomy for distal chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg 2014; 148:1005-11; 1012.e1-2; discussion 1011-2. [DOI: 10.1016/j.jtcvs.2014.06.052] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 06/17/2014] [Accepted: 06/27/2014] [Indexed: 11/27/2022]
|
14
|
Abstract
The pulmonary circulation is a high-flow and low-pressure circuit. The functional state of the pulmonary circulation is defined by pulmonary vascular pressure-flow relationships conforming to distensible vessel models with a correction for hematocrit. The product of pulmonary arterial compliance and resistance is constant, but with a slight decrease as a result of increased pulsatile hydraulic load in the presence of increased venous pressure or proximal pulmonary arterial obstruction. An increase in left atrial pressure is transmitted upstream with a ratio ≥1 for mean pulmonary artery pressure and ≤1 the diastolic pulmonary pressure. Therefore, the diastolic pressure gradient is more appropriate than the transpulmonary pressure gradient to identify pulmonary vascular disease in left heart conditions. Exercise is associated with a decrease in pulmonary vascular resistance and an increase in pulmonary arterial compliance. Right ventricular function is coupled to the pulmonary circulation with an optimal ratio of end-systolic to arterial elastances of 1.5-2.
Collapse
Affiliation(s)
- Robert Naeije
- Department of Physiology, Erasme Campus of the Free University of Brussels, CP 604, 808, Lennik Road, 1070, Brussels, Belgium,
| |
Collapse
|
15
|
Affiliation(s)
- Irene Marthe Lang
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
| | - Michael Madani
- From the Department of Internal Medicine II, Division of Cardiology, Vienna, Austria (I.M.L.); and Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of California–San Diego, La Jolla (M.M.)
| |
Collapse
|
16
|
Yamada N. Operability assessment and postoperative outcome in chronic thromboembolic pulmonary hypertension. Circ J 2014; 78:320-1. [PMID: 24401572 DOI: 10.1253/circj.cj-13-1546] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| |
Collapse
|
17
|
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease with high mortality and few treatment options. This article reviews the epidemiology of CTEPH and identifies risk factors for its development. The pathobiology and the progression from thromboembolic events to chronically increased right-sided pressures are discussed. The diagnosis and assessment of CTEPH requires several modalities and the role of these is detailed. The pre-operative evaluation assesses peri-operative risk and determines the likelihood of benefit from PTE. Pulmonary thromboendarterectomy (PTE) remains the treatment of choice in appropriate patients. Nonsurgical therapies for CTEPH may provide benefit in patients who cannot be offered surgery.
Collapse
Affiliation(s)
- Peter S Marshall
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, 15 York Street, LCI 101, New Haven, CT 06510, USA.
| | | | | |
Collapse
|
18
|
Skoro-Sajer N, Marta G, Gerges C, Hlavin G, Nierlich P, Taghavi S, Sadushi-Kolici R, Klepetko W, Lang IM. Surgical specimens, haemodynamics and long-term outcomes after pulmonary endarterectomy. Thorax 2013; 69:116-22. [PMID: 24052543 PMCID: PMC3913220 DOI: 10.1136/thoraxjnl-2013-203746] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Chronic thromboembolic pulmonary hypertension is surgically curable by pulmonary endarterectomy (PEA). It is unclear whether PEA impacts primarily steady state right ventricular afterload (ie, pulmonary vascular resistance (PVR)) or pulsatile right ventricular afterload (ie, pulmonary arterial compliance (CPA)). Our objectives were to (1) quantify PEA specimens and measure the impact of PEA on PVR and CPA in a structure/function study and (2) analyse the effects of haemodynamic changes on long-term survival/freedom of lung transplantation in an outcome study. Methods Thrombi were laid out, weighed, photographed and measured. PVR, CPA and resistance times compliance (RC-time) were assessed at baseline, within 4 days after PEA (‘immediately postoperative’) and 1 year after PEA, in 110 consecutive patients who were followed for 34.5 (11.9; 78.3) months. Results Lengths and numbers of PEA specimen tails were inversely correlated with immediate postoperative PVR (p<0.0001, r=−0.566; p<0.0001, r=−0.580). PVR and CPA normalised immediately postoperatively while RC-time remained unchanged. Immediate postoperative PVR was the only predictor of long-term survival/freedom of lung transplantation (p<0.0001). Patients with immediate postoperative PVR<590 dynes.s.cm−5 had better long-term outcomes than patients with PVR≥590 dynes.s.cm−5 (p<0.0001, respectively). Conclusions PEA immediately decreased PVR and increased CPA under a constant RC-time. However, immediate postoperative PVR was the only predictor of long-term survival/freedom of lung transplantation. Our study confirms the importance of a complete, bilateral surgical endarterectomy. Low PVR measured immediately postoperative predicts excellent long-term outcome.
Collapse
Affiliation(s)
- Nika Skoro-Sajer
- Department of Internal Medicine II, Division of Cardiology, Vienna General Hospital, Medical University of Vienna, , Vienna, Austria
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Page A, Ali JM, Maraka J, Mackenzie-Ross R, Jenkins DP. Management of chronic thromboembolic pulmonary hypertension: current status and emerging options. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.13.22] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
20
|
Grignola JC, Domingo E. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: How can patients be better selected? World J Cardiol 2013; 5:18-21. [PMID: 23539496 PMCID: PMC3610002 DOI: 10.4330/wjc.v5.i3.18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2012] [Revised: 12/21/2012] [Accepted: 01/19/2013] [Indexed: 02/06/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) comprises organizing thrombotic obstructions in the pulmonary arteries by nonresolving thromboemboli, formation of fibrosis and remodeling of pulmonary blood vessels. Surgical pulmonary endarterectomy (PEA) is the therapy of choice for patients with surgically accessible CTEPH, which leads to a profound improvement in hemodynamics, functional class and survival. Selecting the candidates that will benefit from surgery is still a challenging task. Criteria for surgical suitability have been described but the decision-making for or against surgical intervention remains still subjective. The optimal characterization of the reciprocal contribution of large vessel and small vessel disease in the elevation of pulmonary vascular resistance is crucial for the indication and outcome of PEA. Recently, Toshner et al intended to validate the partition resistance into small and large vessels compartments (upstream resistance: Rup) by the occlusion technique in the preoperative assessment of PEA. We discuss the advantages and disadvantages of Rup and compare it with other hemodynamic predictor to evaluate operative risk in CTEPH patients.
Collapse
|