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Moore J, Altschul E, Remy-Jardin M, Raoof S. Chronic Thromboembolic Pulmonary Hypertension: Clinical and Imaging Evaluation. Clin Chest Med 2024; 45:405-418. [PMID: 38816096 DOI: 10.1016/j.ccm.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and is an important cause of pulmonary hypertension. As a clinical entity, it is frequently underdiagnosed with prolonged diagnostic delays. This study reviews the clinical and radiographic findings associated with CTEPH to improve awareness and recognition. Strengths and limitations of multiple imaging modalities are reviewed. Accompanying images are provided to supplement the text and provide examples of important findings for the reader.
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Affiliation(s)
- Jonathan Moore
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Erica Altschul
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA
| | - Martine Remy-Jardin
- Department of Thoracic Imaging, Univ.Lille, CHU Lille, LILLE F-59000, France; Univ.Lille, CHU Lille, ULR 2694 METRICS Evaluation des Technologies de Santé et des Pratiques Médicales, LILLE F-59000, France
| | - Suhail Raoof
- Department of Pulmonary and Critical Care Medicine, Lenox Hill Hospital, Northwell Health Physician Partners, New York, NY, USA.
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2
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Bertici RA, Bertici NS, Ridichie A, Fira-Mladinescu O. Comorbidities, Treatment and Survival Rates of Chronic Thromboembolic Pulmonary Hypertension in a Regional Centre. J Clin Med 2024; 13:2754. [PMID: 38792295 PMCID: PMC11122045 DOI: 10.3390/jcm13102754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 04/24/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objectives: Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by a multitude of underlying causes, treatment modalities and prognostic outcomes. Our aim was to evaluate the underlying causes, comorbidities and survival rates of CTEPH patients. Methods: A retrospective analysis was conducted regarding the evolution of CTEPH patients confirmed by right heart catheterization under treatment with specific vasodilator medication in our centre between 2008 and 2023. Results: We treated 14 CTEPH patients, 78.57% female, 52.79 ± 13.64 years at inclusion, representing 11.29% of our pulmonary arterial hypertension registry. Initially, the distribution of patients' NYHA class was II-14.28%, III-71.42% and IV-14.28%. In total, 71.42% of these patients were technically operable due to the central location of the thrombus, but 42.85% presented severe comorbidities and 28.57% refused the surgery or it was financially inaccessible. Only four patients were operated on by pulmonary endarterectomy (PEA). Unfortunately, all the post-PEA patients had persistent pulmonary hypertension and had to continue vasodilator treatment. Overall, 64.28% of patients had monotherapy, 21.42% double therapy and 14.28% triple therapy. Regarding underlying causes and comorbidities, we found the following incidences: 78.57% chronic venous insufficiency, 42.85% obesity, 35.71% thyroid disease, hypertension and hyperuricemia, 21.42% thrombophilia and ischemic heart disease, 14.28% atrial fibrillation, vasculitis and lung disease, and 14.28% neoplastic history and diabetes. Seven patients died (50%), six of whom were unoperated and one of whom was lost (abandoned the program). The survival rates at 1, 3, 5 and 7 years for unoperated patients were 100%, 58.3%, 29.2% and 29.2% versus 100%, 75%, 75% and 75% in post-PEA patients. Conclusions: CTEPH, marked by delayed diagnosis, multiple comorbidities and limited intervention options, requires proactive screening and comprehensive multimodal therapies, including PEA, to improve survival rates.
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Affiliation(s)
- Razvan Adrian Bertici
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
| | - Nicoleta Sorina Bertici
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
- Clinical Hospital of Infectious Diseases and Pulmonology Victor Babes Timisoara, Gheorghe Adam Street 13, 300310 Timisoara, Romania
| | - Amalia Ridichie
- Advanced Instrumental Screening Center, Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania;
| | - Ovidiu Fira-Mladinescu
- Department XIII Pulmonology, Victor Babes University of Medicine and Pharmacy Timisoara, Eftimie Murgu Sq. No. 2, 300041 Timisoara, Romania; (R.A.B.); (O.F.-M.)
- Clinical Hospital of Infectious Diseases and Pulmonology Victor Babes Timisoara, Gheorghe Adam Street 13, 300310 Timisoara, Romania
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3
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Gawlitza J, Endres S, Fries P, Graf M, Wilkens H, Stroeder J, Buecker A, Massmann A, Ziegelmayer S. Machine learning assisted feature identification and prediction of hemodynamic endpoints using computed tomography in patients with CTEPH. Int J Cardiovasc Imaging 2024; 40:569-577. [PMID: 38143250 PMCID: PMC10950991 DOI: 10.1007/s10554-023-03026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 11/24/2023] [Indexed: 12/26/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but potentially curable cause of pulmonary hypertension (PH). Currently PH is diagnosed by right heart catheterisation. Computed tomography (CT) is used for ruling out other causes and operative planning. This study aims to evaluate importance of different quantitative/qualitative imaging features and develop a supervised machine learning (ML) model to predict hemodynamic risk groups. 127 Patients with diagnosed CTEPH who received preoperative right heart catheterization and thoracic CTA examinations (39 ECG-gated; 88 non-ECG gated) were included. 19 qualitative/quantitative imaging features and 3 hemodynamic parameters [mean pulmonary artery pressure, right atrial pressure (RAP), pulmonary artery oxygen saturation (PA SaO2)] were gathered. Diameter-based CT features were measured in axial and adjusted multiplane reconstructions (MPR). Univariate analysis was performed for qualitative and quantitative features. A random forest algorithm was trained on imaging features to predict hemodynamic risk groups. Feature importance was calculated for all models. Qualitative and quantitative parameters showed no significant differences between ECG and non-ECG gated CTs. Depending on reconstruction plane, five quantitative features were significantly different, but mean absolute difference between parameters (MPR vs. axial) was 0.3 mm with no difference in correlation with hemodynamic parameters. Univariate analysis showed moderate to strong correlation for multiple imaging features with hemodynamic parameters. The model achieved an AUC score of 0.82 for the mPAP based risk stratification and 0.74 for the PA SaO2 risk stratification. Contrast agent retention in hepatic vein, mosaic attenuation pattern and the ratio right atrium/left ventricle were the most important features among other parameters. Quantitative and qualitative imaging features of reconstructions correlate with hemodynamic parameters in preoperative CTEPH patients-regardless of MPR adaption. Machine learning based analysis of preoperative imaging features can be used for non-invasive risk stratification. Qualitative features seem to be more important than previously anticipated.
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Affiliation(s)
- Joshua Gawlitza
- Clinic/Institute of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Sophie Endres
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424, Homburg, Germany
| | - Peter Fries
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424, Homburg, Germany
| | - Markus Graf
- Clinic/Institute of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Heinrike Wilkens
- Cardiology, Angiology, Pulmonary and Intensive Care, Saarland University Medical Center, Kirrberger Strasse 100, 66424, Homburg, Germany
| | - Jonas Stroeder
- Department of Radiology and Nuclear Medicine, University Hospital Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Arno Buecker
- Clinic for Diagnostic and Interventional Radiology, Saarland University Medical Center, Kirrberger Strasse 100 (Building 41), 66424, Homburg, Germany
| | - Alexander Massmann
- Department of Radiology and Nuclear Medicine, Robert-Bosch-Krankenhaus, Auerbachstr. 110, 70376, Stuttgart, Germany
| | - Sebastian Ziegelmayer
- Clinic/Institute of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
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4
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Pepke-Zaba J, Howard L, Kiely DG, Sweeney S, Johnson M. Pulmonary Embolism (PE) to Chronic Thromboembolic Pulmonary Disease (CTEPD): Findings from a Survey of UK Physicians. Adv Respir Med 2024; 92:45-57. [PMID: 38247551 PMCID: PMC10801485 DOI: 10.3390/arm92010007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/22/2023] [Accepted: 12/22/2023] [Indexed: 01/23/2024]
Abstract
Chronic thromboembolic pulmonary disease (CTEPD) is a complication of pulmonary embolism (PE). We conducted an online survey of UK PE-treating physicians to understand practices in the follow-up of PE and awareness of CTEPD. The physicians surveyed (N = 175) included 50 each from cardiology, respiratory and internal medicine, plus 25 haematologists. Most (89%) participants had local guidelines for PE management, and 65% reported a PE follow-up clinic, of which 69% were joint clinics. Almost half (47%) had a protocol for the investigation of CTEPD. According to participants, 129 (74%) routinely consider a diagnosis of CTEPD and 97 (55%) routinely investigate for CTEPD, with 76% of those 97 participants investigating in patients who are symptomatic at 3 months and 22% investigating in all patients. This survey demonstrated variability in the follow-up of PE and the awareness of CTEPD and its investigation. The findings support the conduct of a national audit to understand the barriers to the timely detection of CTEPD.
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Affiliation(s)
- Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, National Pulmonary Hypertension Service, Royal Papworth Hospital, Cambridge CB2 0AY, UK
| | - Luke Howard
- National Pulmonary Hypertension Service, Hammersmith Hospital, London W12 0HS, UK
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S10 2JF, UK
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, NIHR Biomedical Research Centre, Sheffield S10 2RX, UK
| | - Shruti Sweeney
- Medical Affairs Department, Janssen-Cilag Ltd., High Wycombe HP12 4EG, UK
| | - Martin Johnson
- Scottish Pulmonary Vascular Unit, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
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5
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Joya-Seijo MD, Barrios Garrido-Lestache ME, Rueda-Camino JA, Angelina-García M, Gil-Abizanda AC, Sáenz de Urturi-Rodríguez A, Carrillo Hernández-Rubio J, Del Valle-Loarte P, Salto-Camacho ML, Barba-Martín R. External validation of the InShape II study algorithm for exclusion of chronic thromboembolic pulmonary hypertension in patients with pulmonary thromboembolism. Rev Clin Esp 2023; 223:562-568. [PMID: 37722563 DOI: 10.1016/j.rceng.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/24/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND AND AIM The most severe long-term complication of pulmonary embolism (PE) is chronic thromboembolic pulmonary hypertension (CTEPH), and its early diagnosis often requires numerous diagnostic tests. The InShape II study proposes an early screening algorithm that aims to reduce the number of echocardiographic studies. The objective of our study is to validate this algorithm in our patient cohort. MATERIALS AND METHODS We retrospectively analyzed patients admitted to Hospital Rey Juan Carlos between November 2017 and February 2020, who were diagnosed with PE based on computed tomography angiography (CTA). Patients were followed for at least one year, and clinical, laboratory, and complementary test data were collected at three months and one year. The InShape II algorithm was applied to these patients to validate its results. RESULTS During the study period, 236 patients were diagnosed with PE, of which 137 were excluded. The algorithm was validated in 99 patients. Applying the InShape II score, 19 echocardiograms would have been performed (three of them with intermediate-high probability of CTEPH), while 80 echocardiograms would have been avoided (two of them with intermediate-high probability). This yielded a sensitivity of 60% and a specificity of 83% for the score, with an area under the curve (AUC) of 0.715 (95% CI: 0.472-0.958). CONCLUSIONS Our results support the notion that the InShape II algorithm could be a useful tool for initial screening of CTEPH in low-incidence settings, as it would avoid unnecessary echocardiograms that do not provide additional value.
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Affiliation(s)
- M D Joya-Seijo
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain.
| | - M E Barrios Garrido-Lestache
- Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain; Unidad Enfermedad Tromboembólica, Servicio de Cardiología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - J A Rueda-Camino
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain
| | - M Angelina-García
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain
| | - A C Gil-Abizanda
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - A Sáenz de Urturi-Rodríguez
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - J Carrillo Hernández-Rubio
- Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain; Unidad Enfermedad Tromboembólica, Servicio de Neumología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - P Del Valle-Loarte
- Servicio de Medicina Interna, Hospital Universitario Severo Ochoa, Leganés, Madrid, Spain
| | - M L Salto-Camacho
- Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain; Unidad Enfermedad Tromboembólica, Servicio de Cardiología, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain
| | - R Barba-Martín
- Unidad Enfermedad Tromboembólica, Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, Spain; Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Instituto de Investigación Fundación Jiménez Díaz, Madrid, Spain
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6
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Zuin M, Piazza G, Barco S, Bikdeli B, Hobohm L, Giannakoulas G, Konstantinides S. Time-based reperfusion in haemodynamically unstable pulmonary embolism patients: does early reperfusion therapy improve survival? EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:714-720. [PMID: 37421358 DOI: 10.1093/ehjacc/zuad080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 07/07/2023] [Indexed: 07/10/2023]
Abstract
High-risk pulmonary embolism (PE) is associated with significant morbidity and mortality. Systemic thrombolysis remains the most evidenced-based treatment for haemodynamically unstable PE, but in daily clinical practice, it remains largely underused. In addition, unlike acute myocardial infarction or stroke, a clear time window for reperfusion therapy, including fibrinolysis, for high-risk PE has not been defined either for fibrinolysis or for the more recently incorporated options of catheter-based thrombolysis or thrombectomy. The aim of the present article is to review the current evidence supporting the potential benefit of earlier administration of reperfusion in haemodynamically unstable PE patients and suggest some potential strategies to further explore this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8, Ferrara, 44100, Italy
| | - Gregory Piazza
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - Behnood Bikdeli
- Cardiovascular Medicine Division and Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Yale/YNHH Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
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7
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Fetita C, Richeux J, Didier A, Maury M, Flint J, Brillet PY, Bergot E, Bernaudin JF, Justet A. Comparison between computerised lung SPECT-CT and noncontrast thoracic HRCT for quantitative analysis of post-acute COVID-19 pulmonary vascular pruning. ERJ Open Res 2023; 9:00076-2023. [PMID: 37868150 PMCID: PMC10588800 DOI: 10.1183/23120541.00076-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 08/09/2023] [Indexed: 10/24/2023] Open
Abstract
Computerised processing of images from routine noncontrast HRCT could be an efficient, costless and safe tool to investigate the vascular remodelling that occurs in the months after COVID-19 in a large number of patients https://bit.ly/3qAQZDW.
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Affiliation(s)
- Catalin Fetita
- SAMOVAR, Telecom SudParis, Institut Polytechnique de Paris, Evry, France
- These authors contributed equally
| | - Jean Richeux
- Service de Pneumologie, CHU de Caen, Caen, France
| | - Antoine Didier
- SAMOVAR, Telecom SudParis, Institut Polytechnique de Paris, Evry, France
| | - Mathilde Maury
- SAMOVAR, Telecom SudParis, Institut Polytechnique de Paris, Evry, France
| | - Jasper Flint
- Internal Medicine Department, Pulmonary Critical Care and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, USA
| | - Pierre-Yves Brillet
- Service de Radiologie Hôpital Avicenne, AP-HP, Bobigny, France
- INSERM 1272 Université Sorbonne Paris-Nord, Bobigny, France
| | - Emmanuel Bergot
- Service de Pneumologie, CHU de Caen, Caen, France
- Université de Caen Normandie, CNRS, Normandie Université, ISTCT, UMR6030, GIP Cyceron, Caen, France
| | - Jean-Francois Bernaudin
- INSERM 1272 Université Sorbonne Paris-Nord, Bobigny, France
- Faculté de Médecine Sorbonne Université Paris, Paris, France
- These authors contributed equally
| | - Aurélien Justet
- Service de Pneumologie, CHU de Caen, Caen, France
- Internal Medicine Department, Pulmonary Critical Care and Sleep Medicine Section, Yale School of Medicine, New Haven, CT, USA
- Université de Caen Normandie, CNRS, Normandie Université, ISTCT, UMR6030, GIP Cyceron, Caen, France
- These authors contributed equally
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8
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Tsiamita O, White K. Post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension: diagnosis and management. Br J Hosp Med (Lond) 2023; 84:1-10. [PMID: 37646549 DOI: 10.12968/hmed.2023.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Post-thrombotic syndrome and chronic thromboembolic pulmonary hypertension are two distinct clinical syndromes associated with adverse patient outcomes following a venous thromboembolism. Clinical manifestations of post-thrombotic syndrome include persistent pain, swelling and ultimately venous ulceration following a deep venous thrombosis. Patients experiencing chronic thromboembolic pulmonary hypertension may have symptoms ranging from exertional dyspnoea to overt right heart failure. From a physician's perspective, the most effective preventative strategy is good quality anticoagulation for prophylaxis of primary and secondary venous thromboembolism. The treatment of post-thrombotic syndrome mainly involves lifestyle modifications alongside the use of elastic compression stockings while patients with chronic thromboembolic pulmonary hypertension should be offered targeted surgical and medical treatment options available at expert centres. Further research is warranted for both conditions to determine the role of direct oral anticoagulants when used with a preventive or therapeutic intent.
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Affiliation(s)
- Olga Tsiamita
- Department of Clinical Haematology, Barts Health NHS Trust, London, UK
| | - Katie White
- Department of Clinical Haematology, Barts Health NHS Trust, London, UK
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9
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Yuriditsky E, Horowitz JM, Lau JF. Chronic thromboembolic pulmonary hypertension and the post-pulmonary embolism (PE) syndrome. Vasc Med 2023; 28:348-360. [PMID: 37036116 DOI: 10.1177/1358863x231165105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Over a third of patients surviving acute pulmonary embolism (PE) will experience long-term cardiopulmonary limitations. Persistent thrombi, impaired gas exchange, and altered hemodynamics account for aspects of the postpulmonary embolism syndrome that spans mild functional limitations to debilitating chronic thromboembolic pulmonary hypertension (CTEPH), the most worrisome long-term consequence. Though pulmonary endarterectomy is potentially curative for the latter, less is understood surrounding chronic thromboembolic disease (CTED) and post-PE dyspnea. Advances in pulmonary vasodilator therapies and growing expertise in balloon pulmonary angioplasty provide options for a large group of patients ineligible for surgery, or those with persistent postoperative pulmonary hypertension. In this clinical review, we discuss epidemiology and pathophysiology as well as advances in diagnostics and therapeutics surrounding the spectrum of disease that may follow months after acute PE.
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Affiliation(s)
- Eugene Yuriditsky
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - James M Horowitz
- Department of Medicine, Division of Cardiology, NYU Langone Health, New York, NY, USA
| | - Joe F Lau
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, USA
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10
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Gleditsch J, Jervan Ø, Klok F, Holst R, Hopp E, Tavoly M, Ghanima W. Does the clot burden as assessed by the Mean Bilateral Proximal Extension of the Clot score reflect mortality and adverse outcome after pulmonary embolism? Acta Radiol Open 2023; 12:20584601231187094. [PMID: 37426515 PMCID: PMC10328056 DOI: 10.1177/20584601231187094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 06/24/2023] [Indexed: 07/11/2023] Open
Abstract
Background Rapid diagnosis and risk stratification are important to reduce the risk of adverse clinical events and mortality in acute pulmonary embolism (PE). Although clot burden has not been consistently shown to correlate with disease outcomes, proximally located PE is generally perceived as more severe. Purpose To explore the ability of the Mean Bilateral Proximal Extension of the Clot (MBPEC) score to predict mortality and adverse outcome. Methods This was a single center retrospective cohort study. 1743 patients with computed tomography pulmonary arteriography (CTPA) verified PE diagnosed between 2005 and 2020 were included. Patients with active malignancy were excluded. The PE clot burden was assessed with MBPEC score: The most proximal extension of PE was scored in each lung from 1 = sub-segmental to 4 = central. The MBPEC score is the score from each lung divided by two and rounded up to nearest integer. Results We found inconsistent associations between higher and lower MBPEC scores versus mortality. The all-cause 30-day mortality of 3.9% (95% CI: 3.0-4.9). The PE-related mortality was 2.4% (95% CI: 1.7-3.3). Patients with MBPEC score 1 had higher all-cause mortality compared to patients with MBPEC score 4: Crude Hazard Ratio (cHR) was 2.02 (95% CI: 1.09-3.72). PE-related mortality was lower in patients with MBPEC score 3 compared to score 4: cHR 0.22 (95% CI: 0.05-0.93). Patients with MBPEC score 4 did more often receive systemic thrombolysis compared to patients with MBPEC score 1-3: 3.2% vs. 0.6% (p < .001). Patients with MBPEC score 4 where more often admitted to the intensive care unit: 13% vs. 4.7% (p < .001). Conclusion We found no consistent association between the MBPEC score and mortality. Our results therefore indicate that peripheral PE does not necessarily entail a lower morality risk than proximal PE.
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Affiliation(s)
- Jostein Gleditsch
- Department of Radiology, Østfold Hospital, Kalnes, Norway
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
| | - Øyvind Jervan
- Institute of Clinical Medicine, University of Oslo Faculty of
Medicine, Oslo, Norway
- Department of Cardiology, Østfold Hospital, Kalnes, Norway
| | - Frederikus Klok
- Department of Medicine – Thrombosis
and Hemostasis, Leiden University Medical
Center, Leiden, The Netherlands
| | - René Holst
- Oslo Centre for Biostatistics and
Epidemiology, University of Oslo and Oslo
University Hospital, Oslo, Norway
| | - Einar Hopp
- Division of Radiology and Nuclear
Medicine, Oslo University
Hospital, Oslo, Norway
| | - Mazdak Tavoly
- Department of Medicine, Sahlgrenska University
Hospital, Gothenburg, Sweden
| | - Waleed Ghanima
- Internal Medicine Clinic, Østfold Hospital, Kalnes, Norway
- Department of Hematology, Oslo
University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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11
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Zhai Z, Boon GJAM, Staring M, van Dam LF, Kroft LJM, Hernández Girón I, Ninaber MK, Bogaard HJ, Meijboom LJ, Vonk Noordegraaf A, Huisman MV, Klok FA, Stoel BC. Automated quantification of the pulmonary vasculature in pulmonary embolism and chronic thromboembolic pulmonary hypertension. Pulm Circ 2023; 13:e12223. [PMID: 37128354 PMCID: PMC10148047 DOI: 10.1002/pul2.12223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 05/03/2023] Open
Abstract
The shape and distribution of vascular lesions in pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH) are different. We investigated whether automated quantification of pulmonary vascular morphology and densitometry in arteries and veins imaged by computed tomographic pulmonary angiography (CTPA) could distinguish PE from CTEPH. We analyzed CTPA images from a cohort of 16 PE patients, 6 CTEPH patients, and 15 controls. Pulmonary vessels were extracted with a graph-cut method, and separated into arteries and veins using deep-learning classification. Vascular morphology was quantified by the slope (α) and intercept (β) of the vessel radii distribution. To quantify lung perfusion defects, the median pulmonary vascular density was calculated. By combining these measurements with densities measured in parenchymal areas, pulmonary trunk, and descending aorta, a static perfusion curve was constructed. All separate quantifications were compared between the three groups. No vascular morphology differences were detected in contrast to vascular density values. The median vascular density (interquartile range) was -567 (113), -452 (95), and -470 (323) HU, for the control, PE, and CTEPH group. The static perfusion curves showed different patterns between groups, with a statistically significant difference in aorta-pulmonary trunk gradient between the PE and CTEPH groups (p = 0.008). In this proof of concept study, not vasculature morphology but densities differentiated between patients of three groups. Further technical improvements are needed to allow for accurate differentiation between PE and CTEPH, which in this study was only possible statistically by measuring the density gradient between aorta and pulmonary trunk.
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Affiliation(s)
- Zhiwei Zhai
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Gudula J. A. M. Boon
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Marius Staring
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Lisette F. van Dam
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Lucia J. M. Kroft
- Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Irene Hernández Girón
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Maarten K. Ninaber
- Department of PulmonologyLeiden University Medical CenterLeidenThe Netherlands
| | - Harm Jan Bogaard
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Lilian J. Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
| | - Menno V. Huisman
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine ‐ Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Berend C. Stoel
- Division of Image Processing, Department of RadiologyLeiden University Medical CenterLeidenThe Netherlands
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12
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Hahn LD, Papamatheakis DG, Fernandes TM, Poch DS, Yang J, Shen J, Hoh CK, Hsiao A, Kerr KM, Pretorius V, Madani MM, Kim NH, Kligerman SJ. Multidisciplinary Approach to Chronic Thromboembolic Pulmonary Hypertension: Role of Radiologists. Radiographics 2023; 43:e220078. [DOI: 10.1148/rg.220078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Lewis D. Hahn
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Demosthenes G. Papamatheakis
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Timothy M. Fernandes
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - David S. Poch
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jenny Yang
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Jody Shen
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Carl K. Hoh
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Albert Hsiao
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Kim M. Kerr
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Victor Pretorius
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Michael M. Madani
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Nick H. Kim
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
| | - Seth J. Kligerman
- From the Departments of Radiology (L.D.H., C.K.H., A.H., S.J.K.), Pulmonology (D.G.P., T.M.F., D.S.P., J.Y., C.K.H., K.M.K., N.H.K.), and Cardiothoracic Surgery (V.P., M.M.M.), University of California San Diego School of Medicine, 9300 Campus Point Dr, La Jolla, CA 92037-0841; and Department of Radiology, Stanford School of Medicine, Palo Alto, Calif (J.S.)
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13
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Kong J, Hardwick A, Jiang SF, Sun K, Vinson DR, McGlothlin DP, Goh CH. CTEPH: A Kaiser Permanente Northern California Experience. Thromb Res 2023; 221:130-136. [PMID: 36566069 DOI: 10.1016/j.thromres.2022.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/23/2022] [Accepted: 09/24/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and life-threatening form of pulmonary hypertension and the only potentially curable form of the World Health Organization Pulmonary Hypertension classes. Thus, the prompt and accurate diagnosis of this condition is imperative. Despite widespread chronic symptoms following acute pulmonary embolism (PE), the condition is rarely considered, and an externally validated inexpensive diagnostic algorithm is lacking. METHODS A long-term, retrospective cohort study was conducted to assess the incidence of CTEPH following acute PE in a real-world study population. Additional data were collected regarding the practice patterns of diagnostic testing and imaging, particularly in patients with persistent or recurrent symptoms. Amongst diagnosed CTEPH patients, previously established risk factors were evaluated for degree of risk and commonly used diagnostic tests (electrocardiogram [ECG] right ventricular hypertrophy [RVH] pattern, B-type natriuretic peptide [BNP] elevations) employed during this period were evaluated and assessed for feasibility as screening tests. The study population was obtained from the MAPLE study cohort, comprised of patients presenting with acute PE in 21 community medical centers across the Kaiser Permanente Northern California system from January 2013 to April 2015. Diagnosis of CTEPH was confirmed via pulmonary vascular imaging (ventilation/perfusion [V/Q] scanning, computed tomography angiography, pulmonary angiography) and diagnostic right heart catheterization (RHC). Probable diagnoses were defined as a combination of suggestive echocardiographic and RHC findings. Additional inclusion criteria included age (≥18 years) with at least 2 years follow up and no previous diagnosis of CTEPH or PE during the prior 30 days. RESULTS There were 1973 patients who met inclusion criteria (mean age 62.4 years). Despite 75 % of patients developing symptoms consistent with CTEPH >3 months following acute PE, only 5.6 % of these symptomatic patients underwent V/Q scanning. There was overall a very low cumulative incidence of CTEPH (2.3 %), which was significantly higher amongst patients with symptoms compared to those without symptoms. When controlled for confounding in the multivariate analysis, only recurrent PE (HR 19.3, P < 0.001) and pulmonary artery systolic pressure >50 mmHg (HR 10.4, P < 0.001) were statistically significant predictors of CTEPH. Of the non-invasive diagnostic tests, ECG criteria for RVH were found to be poorly sensitive (2.6 %), but very specific (98.8 %) for CTEPH. Elevated levels of BNP alone were more sensitive than RVH ECG criteria (76.3 %) but poorly specific (44.4 %). CONCLUSIONS The diagnosis of CTEPH is uncommonly made following acute PE. Despite the frequency of persistent symptoms consistent with CTEPH following acute PE, the appropriate diagnostic work-up is rarely undertaken as evidenced in this cohort. This suggests that CTEPH is underappreciated and rarely considered, likely underestimating the true incidence in this cohort. Future studies are needed to elucidate the true prevalence of CTEPH and further investigate both the optimal diagnostic tools and timing of appropriate screening. These discoveries may help guide future development of diagnostic algorithms that can effectively rule out and accurately identify this potentially curable disease in a timely manner.
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Affiliation(s)
- Jeremy Kong
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA.
| | | | - Sheng-Fang Jiang
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Ke Sun
- Department of Internal Medicine, Kaiser Permanente Mid-Atlantic, Gaithersburg, MD
| | - David R Vinson
- Division of Research, Kaiser Permanente Northern California, Oakland, CA; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA
| | - Dana P McGlothlin
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
| | - Choon Hwa Goh
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA
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14
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Cardiopulmonary Exercise Testing in Pulmonary Arterial Hypertension. Heart Fail Clin 2023; 19:35-43. [DOI: 10.1016/j.hfc.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Improved long-term outcomes with catheter-directed therapies over medical management in patients with submassive pulmonary embolism-a retrospective matched cohort study. J Vasc Surg Venous Lymphat Disord 2023; 11:70-81. [PMID: 36210021 PMCID: PMC10024252 DOI: 10.1016/j.jvsv.2022.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND The benefit of catheter-directed therapy (CDT) for submassive pulmonary embolism (sPE) has been the subject of debate. We sought to determine the short- and long-term mortality and outcomes of CDT compared with anticoagulation for patients with sPE. METHODS We performed a single healthcare network, multihospital, retrospective cohort study of hospitalizations for sPE from 2012 to 2019. sPE was defined as the presence of right heart strain or elevated biomarkers (troponin I or B-type natriuretic peptide). Patients with massive PE and those who had undergone systemic thrombolysis were excluded. The sPE groups included therapeutic anticoagulation alone or anticoagulation plus CDT (ie, thrombolysis or suction thrombectomy). The primary outcome was mortality at 1, 3, and 5 years. The other measured outcomes included PE-related death, short term mortality (30 days and 3 and 6 months), 30-day treatment-related complications (eg, bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test at 1 year. After 1:1 nearest-neighbor propensity score matching, Kaplan-Meier survival plots were generated, and the treatment groups were compared using log-rank testing. We used Cox multivariate analysis to evaluate the outcomes after clustering at the hospital level, generating matched hazard ratios (mHRs) with associated 95% confidence intervals (CIs). RESULTS Of 6746 sPE hospitalizations, the patients who had received CDT were younger (age, 58.9 ± 15.5 years vs 61.5 ± 17.4 years; P = .004), were more frequently White (92.5% vs 85.7%; P < .001), and had presented with a higher mean heart rate (104.6 bpm vs 94.9 bpm; P < .001), lower median systolic blood pressure (129 mm Hg vs 135 mm Hg; P < .001), and a greater incidence of right heart strain (79.2% vs 20.3%; P < .001). A total of 470 patients were matched, with 235 in the CDT group and 235 in the anticoagulation-only group. CDT was associated with a lower risk of mortality compared with anticoagulation at 1 year (7.6% vs 9.8%; mHR, 0.77; 95% CI, 0.65-0.92; P = .004), 3 years (11.1% vs 16.6%; mHR, 0.64; 95% CI, 0.55-0.73; P < .001), and 5 years (14.5% vs 19.1%; mHR, 0.71; 95% CI, 0.66-0.77; P < .001). Anticoagulation alone resulted in a greater incidence of PE-related deaths at 1, 3, and 5 years. The mortality at 30 days and 3 months was similar; however, CDT had resulted in better survival at 6 months (mHR, 0.81; 95% CI, 0.68-0.97; P = .02). No differences were found between the two groups in the incidence of bleeding complications at 30 days, development of chronic thromboembolic pulmonary hypertension, or the mean walking distance at 1 year. CONCLUSIONS CDT plus anticoagulation for sPE was associated with improved long-term survival compared with anticoagulation alone, with a lower incidence of PE-related death and a low complication rate. CDT should be considered for select patients with sPE given its survival benefit.
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16
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Fauché A, Presles E, Sanchez O, Jaïs X, Le Mao R, Robin P, Pernod G, Bertoletti L, Jego P, Parent F, Lemarié CA, Leven F, Le Roux PY, Salaun PY, Nonent M, Girard P, Lacut K, Savale L, Mélac S, Guégan M, Mismetti P, Laporte S, Leroyer C, Montani D, Couturaud F, Tromeur C. Frequency and predictors for chronic thromboembolic pulmonary hypertension after a first unprovoked pulmonary embolism: Results from PADIS studies. J Thromb Haemost 2022; 20:2850-2861. [PMID: 36017744 DOI: 10.1111/jth.15866] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/10/2022] [Accepted: 08/08/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening complication of a pulmonary embolism (PE) whose incidence and predictors are not precisely determined. OBJECTIVE To determine the frequency and predictors for CTEPH after a first unprovoked PE. PATIENTS/METHODS In a randomized trial comparing an additional 18-month warfarin versus placebo in patients after a first unprovoked PE initially treated with vitamin K antagonist for 6 months, we applied recommended CTEPH screening strategies through an 8-year follow-up to determine cumulative incidence of CTEPH. CTEPH predictors were estimated using Cox models. Pulmonary vascular obstruction (PVO) and systolic pulmonary arterial pressure (sPAP) at PE diagnosis and 6 months were studied by receiver operating curves analysis. All CTEPH cases and whether they were incident or prevalent were adjudicated. RESULTS During a median follow-up of 8.7 years, nine CTEPH cases were diagnosed among 371 patients, with a cumulative incidence of 2.8% (95% confidence interval [CI] 0.95-4.64), and of 1.31% (95% CI 0.01-2.60) after exclusion of five cases adjudicated as prevalent. At PE diagnosis, PVO > 45% and sPAP > 56 mmHg were associated with CTEPH with a hazard ratio (HR) of 33.00 (95% CI 1.64-667.00, p = .02) and 12.50 (95% CI 2.10-74.80, p < .01), respectively. Age > 65 years, lupus anticoagulant antibodies and non-O blood groups were also predictive of CTEPH. PVO > 14% and sPAP > 34 mmHg at 6 months were associated with CTEPH (HR 63.90 [95% CI 3.11-1310.00, p < .01]and HR 17.2 [95% CI 2.75-108, p < .01]). CONCLUSION After a first unprovoked PE, CTEPH cumulative incidence was 2.8% during an 8-year follow-up. PVO and sPAP at PE diagnosis and at 6 months were the main predictors for CTEPH diagnosis.
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Affiliation(s)
- Alexandre Fauché
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
| | - Emilie Presles
- Unité de recherche clinique, Innovation et pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, Saint-Etienne, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Olivier Sanchez
- F-CRIN INNOVTE, Saint Etienne, France
- Université de Paris, Service de Pneumologie et de soins intensifs, Hôpital Européen Georges Pompidou, AP-HP, and INSERM UMR S 1140, Paris, France
| | - Xavier Jaïs
- AP-HP, Service de pneumologie et soins intensifs respiratoires, Faculty of Medicine, Hôpital Bicêtre, and INSERM UMR_S 999, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Raphael Le Mao
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Philippe Robin
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Nucléaire and INSERM U1304, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Gilles Pernod
- F-CRIN INNOVTE, Saint Etienne, France
- Département de Médecine Vasculaire, Centre Hospitalo-Universitaire de Grenoble, Université de Grenoble 1, Grenoble, France
| | - Laurent Bertoletti
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, Centre Hospitalo-Universitaire de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, Saint-Etienne, France
| | - Patrick Jego
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Interne, Centre Hospitalo-Universitaire de Rennes, Université de Rennes 1, Rennes, France
| | - Florence Parent
- F-CRIN INNOVTE, Saint Etienne, France
- AP-HP, Service de pneumologie et soins intensifs respiratoires, Faculty of Medicine, Hôpital Bicêtre, and INSERM UMR_S 999, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Catherine A Lemarié
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Florent Leven
- Service de Cardiologie and INSERM U1304, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Pierre-Yves Le Roux
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Nucléaire and INSERM U1304, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Pierre-Yves Salaun
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Nucléaire and INSERM U1304, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Michel Nonent
- Service de Radiologie, and INSERM U1304, CIC INSERM 1412, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, Brest, France
| | - Philippe Girard
- F-CRIN INNOVTE, Saint Etienne, France
- Département Thoracique, Institut Mutualiste Montsouris, Paris, France
| | - Karine Lacut
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Laurent Savale
- AP-HP, Service de pneumologie et soins intensifs respiratoires, Faculty of Medicine, Hôpital Bicêtre, and INSERM UMR_S 999, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Solen Mélac
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Marie Guégan
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Patrick Mismetti
- F-CRIN INNOVTE, Saint Etienne, France
- Service de Médecine Vasculaire et Thérapeutique, Unité de Pharmacologie Clinique, CIC1408, Centre Hospitalo-Universitaire de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, Saint-Etienne, France
| | - Silvy Laporte
- Unité de recherche clinique, Innovation et pharmacologie, Centre Hospitalo-Universitaire de Saint-Etienne, and INSERM U1059 SAINBIOSE, Université Jean Monnet, Saint-Etienne, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Christophe Leroyer
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - David Montani
- AP-HP, Service de pneumologie et soins intensifs respiratoires, Faculty of Medicine, Hôpital Bicêtre, and INSERM UMR_S 999, Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
| | - Cécile Tromeur
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, Université de Bretagne Occidentale, and INSERM U1304, CIC INSERM 1412, Brest, France
- F-CRIN INNOVTE, Saint Etienne, France
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Lambert L, Michalek P, Burgetova A. The diagnostic performance of CT pulmonary angiography in the detection of chronic thromboembolic pulmonary hypertension-systematic review and meta-analysis. Eur Radiol 2022; 32:7927-7935. [PMID: 35482124 DOI: 10.1007/s00330-022-08804-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 03/24/2022] [Accepted: 04/05/2022] [Indexed: 01/03/2023]
Abstract
OBJECTIVES To examine the diagnostic performance of CT of the pulmonary artery (CTPA) as a potential first-choice imaging modality in patients with pulmonary arterial hypertension and suspected chronic thromboembolic pulmonary hypertension (CTEPH). METHODS A systematic review and meta-analysis were conducted in accordance with the PRISMA reporting checklist. Six scientific databases and registers (PubMed, EMBASE, Scopus, Web of Science, Cochrane, ClinicalTrials.gov ) were searched for studies evaluating the diagnostic performance of CTPA in suspected CTEPH in adult patients. Results were pooled separately for studies based on the evaluation of the pulmonary artery and those that relied solely on changes in parenchymal perfusion. RESULTS Ten single-center studies with 734 patients were eligible for pooling of the diagnostic performance of CTPA by evaluation of the pulmonary artery. The pooled sensitivity, specificity, PPV, NPV, accuracy, and diagnostic odds ratio (DOR) estimates for CTPA in the detection of CTEPH were 0.98, 0.99, 0.94, 1.00, 0.96, 0.96, and 292. Evaluation of perfusion changes yielded pooled estimates for sensitivity, specificity, PPV, NPV, accuracy, and DOR of 0.99, 0.84, 0.79, 0.98, 0.89, 0.89, and 98 across four studies with 278 patients. Scintigraphy, SPECT, digital subtraction angiography, right heart catheterization, pulmonary endarterectomy, and international guidelines were used to establish the diagnosis. CONCLUSION CTPA has high sensitivity and specificity in the detection of CTEPH when the examination is evaluated by expert radiologists. Evaluation of parenchymal perfusion alone is associated with slightly lower specificity. Further research is needed to determine the diagnostic performance of CTPA in excluding CTEPH in general radiology departments. KEY POINTS • CT pulmonary angiography (CTPA) is recommended in the diagnostic workup of chronic thromboembolic pulmonary hypertension (CTEPH). • CTPA has high sensitivity and specificity in the detection of CTEPH when evaluated by an expert radiologist. • Evaluation of changes in parenchymal perfusion alone is associated with slightly lower specificity. • Little is known about the diagnostic performance of CTPA in the detection of CTEPH in general radiology departments.
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Affiliation(s)
- Lukas Lambert
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic.
| | - Pavel Michalek
- Department of Anaesthesiology, Resuscitation and Intensive Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
| | - Andrea Burgetova
- Department of Radiology, First Faculty of Medicine, Charles University and General University Hospital in Prague, U Nemocnice 2, 128 08, Prague 2, Czech Republic
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Luijten D, Meijer FMM, Boon GJAM, Ende-Verhaar YM, Bavalia R, El Bouazzaoui LH, Delcroix M, Huisman MV, Mairuhu ATA, Middeldorp S, Pruszcyk P, Ruigrok D, Verhamme P, Vonk Noordegraaf A, Vriend JWJ, Vliegen HW, Klok FA. Diagnostic efficacy of ECG-derived ventricular gradient for the detection of chronic thromboembolic pulmonary hypertension in patients with acute pulmonary embolism. J Electrocardiol 2022; 74:94-100. [PMID: 36057190 DOI: 10.1016/j.jelectrocard.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/03/2022] [Accepted: 08/19/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Application of the chronic thromboembolic pulmonary hypertension (CTEPH) rule out criteria (manual electrocardiogram [ECG] reading and N-terminal pro-brain natriuretic peptide [NTproBNP] test) can rule out CTEPH in pulmonary embolism (PE) patients with persistent dyspnea (InShape II algorithm). Increased pulmonary pressure may also be identified using automated ECG-derived ventricular gradient optimized for right ventricular pressure overload (VG-RVPO). METHOD A predefined analysis of the InShape II study was performed. The diagnostic performance of the VG-RVPO for the detection of CTEPH and the incremental diagnostic value of the VG-RVPO as new rule-out criteria in the InShape II algorithm were evaluated. RESULTS 60 patients were included; 5 (8.3%) were ultimately diagnosed with CTEPH. The mean baseline VG-RVPO (at time of PE diagnosis) was -18.12 mV·ms for CTEPH patients and - 21.57 mV·ms for non-CTEPH patients (mean difference 3.46 mV·ms [95%CI -29.03 to 35.94]). The VG-RVPO (after 3-6 months follow-up) normalized in patients with and without CTEPH, without a clear between-group difference (mean Δ VG-RVPO of -8.68 and - 8.42 mV·ms respectively; mean difference of -0.25 mV·ms, [95%CI -12.94 to 12.44]). The overall predictive accuracy of baseline VG-RVPO, follow-up RVPO and Δ VG-RVPO for CTEPH was moderate to poor (ROC AUC 0.611, 0.514 and 0.539, respectively). Up to 76% of the required echocardiograms could have been avoided with VG-RVPO criteria replacing the InShape II rule-out criteria, however at cost of missing up to 80% of the CTEPH diagnoses. CONCLUSION We could not demonstrate (additional) diagnostic value of VG-RVPO as standalone test or as on top of the InShape II algorithm.
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Affiliation(s)
- Dieuwke Luijten
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Fleur M M Meijer
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Yvonne M Ende-Verhaar
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Roisin Bavalia
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Marion Delcroix
- Department of Pneumology, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Teaching Hospital, The Hague, the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Piotr Pruszcyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warszawa, Poland
| | - Dieuwertje Ruigrok
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology, University Hospitals Leuven, Leuven, Belgium
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam UMC, VU University Medical Centre, Amsterdam, the Netherlands
| | - Joris W J Vriend
- Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Lyhne MD, Witkin AS, Dasegowda G, Tanayan C, Kalra MK, Dudzinski DM. Evaluating cardiopulmonary function following acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:747-760. [PMID: 35920239 DOI: 10.1080/14779072.2022.2108789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
INTRODUCTION Pulmonary embolism is a common cause of cardiopulmonary mortality and morbidity worldwide. Survivors of acute pulmonary embolism may experience dyspnea, report reduced exercise capacity, or develop overt pulmonary hypertension. Clinicians must be alert for these phenomena and appreciate the modalities and investigations available for evaluation. AREAS COVERED In this review, the current understanding of available contemporary imaging and physiologic modalities is discussed, based on available literature and professional society guidelines. The purpose of the review is to provide clinicians with an overview of these modalities, their strengths and disadvantages, and how and when these investigations can support the clinical work-up of patients post-pulmonary embolism. EXPERT OPINION Echocardiography is a first test in symptomatic patients post-pulmonary embolism, with ventilation/perfusion scanning vital to determination of whether there is chronic residual emboli. The role of computed tomography and magnetic resonance in assessing the pulmonary arterial tree in post-pulmonary embolism patients is evolving. Functional testing, in particular cardiopulmonary exercise testing, is emerging as an important modality to quantify and determine cause of functional limitation. It is possible that future investigations of the post-pulmonary embolism recovery period will better inform treatment decisions for acute pulmonary embolism patients.
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Affiliation(s)
- Mads Dam Lyhne
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital and Department of Clinical Medicine, Aarhus University, Denmark
| | - Alison S Witkin
- Department of Pulmonary Medicine and Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Giridhar Dasegowda
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Christopher Tanayan
- Cardiovascular Performance Program, Massachusetts General Hospital, Boston, MA, USA
| | - Mannudeep K Kalra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - David M Dudzinski
- Department of Cardiology, Massachusetts General Hospital, Boston, MA, USA.,Echocardiography Laboratory, Massachusetts General Hospital, Boston, MA, USA
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20
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Diagnostic Management of Acute Pulmonary Embolism in COVID-19 and Other Special Patient Populations. Diagnostics (Basel) 2022; 12:diagnostics12061350. [PMID: 35741160 PMCID: PMC9221574 DOI: 10.3390/diagnostics12061350] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 12/28/2022] Open
Abstract
Venous thromboembolism (VTE), in particular acute pulmonary embolism (PE), has been shown to be a frequent and potentially fatal complication of coronavirus disease 2019 (COVID-19). In response to the observed thrombotic complications, a large number of studies has been devoted to the understanding and management of COVID-19-associated coagulopathy. Notably, only a limited number of mostly retrospective studies has focused on the optimal diagnostic strategy for suspected PE in COVID-19 patients. As in other special populations, the accuracy of diagnostic algorithms for PE-exclusion has been debated in this specific patient subgroup as the specificity of D-dimer assays and clinical decision rules (CDRs) may be lower than normal. From this viewpoint, we discuss the current state-of-the-art diagnostic algorithms for acute PE with a focus on patients with COVID-19 in the perspective of other special patient populations. Furthermore, we summarize current knowledge regarding the natural history of PE resolution with anticoagulant treatment in patients with COVID-19.
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21
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Liu Z, Liu X, Lin F, Zheng X, Yang Y, Zhang Y, Fang Y, Ye Z, Liu P, Sun G, Zhen Y. Duration of regional cerebral oxygen saturation under 40% is a risk factor for neurological injury following pulmonary thromboendarterectomy: A prospective observational study. J Card Surg 2022; 37:2610-2617. [PMID: 35599016 DOI: 10.1111/jocs.16615] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Revised: 04/13/2022] [Accepted: 04/15/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Zhan Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xiaopeng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Fan Lin
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Xia Zheng
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yuguang Yang
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yajun Zhang
- Department of Surgical Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Yinghui Fang
- Department of Surgical Anesthesiology, China-Japan Friendship Hospital, Beijing, China
| | - Zhidong Ye
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Peng Liu
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Guang Sun
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
| | - Yanan Zhen
- Department of Cardiovascular Surgery, China-Japan Friendship Hospital, Peking University China-Japan Friendship School of Clinical Medicine, Beijing, China
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22
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Vrigkou E, Tsantes A, Konstantonis D, Rapti E, Maratou E, Pappas A, Halvatsiotis P, Tsangaris I. Platelet, Fibrinolytic and Other Coagulation Abnormalities in Newly-Diagnosed Patients with Chronic Thromboembolic Pulmonary Hypertension. Diagnostics (Basel) 2022; 12:diagnostics12051238. [PMID: 35626393 PMCID: PMC9141147 DOI: 10.3390/diagnostics12051238] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/10/2022] [Accepted: 05/13/2022] [Indexed: 12/31/2022] Open
Abstract
The pathophysiological background of chronic thromboembolic pulmonary hypertension (CTEPH) has not been fully elucidated. Evidence suggests that abnormal platelet function and ineffective fibrinolysis may play a key role in the development of the disease. The purpose of this study was to evaluate platelet and coagulation function in CTEPH, using non-conventional global coagulation assays, and platelet activation and endothelial dysfunction laboratory markers. A total of 40 newly-diagnosed CTEPH patients were studied, along with 35 healthy controls. Blood samples from CTEPH patients were taken directly from the pulmonary artery. All subjects were assessed with platelet function analyzer-100, light transmission aggregometry, thromboelastometry, endogenous thrombin potential. von Willebrand antigen and activity, p-selectin, thromboxane A2 and serotonin levels were also assessed. The results showed that CTEPH patients present diminished platelet aggregation, presence of disaggregation, decreased rate of fibrinolysis, defective thrombin generation and increased levels of thromboxane A2, p-selectin, von Willebrand antigen and activity. Serotonin levels did not present any differences between the two groups. The results of this study suggest that CTEPH patients present platelet function, fibrinolytic, thrombin generation and other clot formation abnormalities. Well-designed clinical studies are needed to further evaluate the complex hemostatic abnormalities in the CTEPH setting and assess their potential clinical applications.
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Affiliation(s)
- Eleni Vrigkou
- Second Department of Critical Care Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.V.); (D.K.); (A.P.)
| | - Argirios Tsantes
- Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (E.R.)
| | - Dimitrios Konstantonis
- Second Department of Critical Care Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.V.); (D.K.); (A.P.)
| | - Evdoxia Rapti
- Laboratory of Hematology and Blood Bank Unit, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (A.T.); (E.R.)
| | - Eirini Maratou
- Laboratory of Clinical Biochemistry, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Athanasios Pappas
- Second Department of Critical Care Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.V.); (D.K.); (A.P.)
| | - Panagiotis Halvatsiotis
- Second Department of Internal Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece;
| | - Iraklis Tsangaris
- Second Department of Critical Care Medicine, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece; (E.V.); (D.K.); (A.P.)
- Correspondence:
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23
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de Perrot M, Donahoe L, McRae K, Thenganatt J, Moric J, Chan J, McInnis M, Jumaa K, Tan KT, Mafeld S, Granton J, Weatherald J, Hirani N, Thakrar M, Helmersen D, Swiston J, Brunner N, Levy R, Mehta S, Kapasi A, Lien D, Michelakis E, Hernandez P, Kemp K, Hirsch A, Langleben D, Hambly N, Dorasamy P, D'Arsigny C, Chandy G, Mielniczuk LM, Christiansen D, Fox G, Laframboise K, Provencher S. Outcome After Pulmonary Endarterectomy For Segmental Chronic Thromboembolic Pulmonary Hypertension. J Thorac Cardiovasc Surg 2022; 164:696-707.e4. [DOI: 10.1016/j.jtcvs.2021.10.078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 10/19/2021] [Accepted: 10/22/2021] [Indexed: 11/17/2022]
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24
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Verbelen T, Godinas L, Maleux G, Coolen J, Claessen G, Belge C, Meyns B, Delcroix M. Chronic thromboembolic pulmonary hypertension: diagnosis, operability assessment and patient selection for pulmonary endarterectomy. Ann Cardiothorac Surg 2022; 11:82-97. [PMID: 35433370 PMCID: PMC9012197 DOI: 10.21037/acs-2021-pte-12] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/08/2021] [Indexed: 07/30/2023]
Abstract
Healthcare providers outside pulmonary hypertension (PH) centers having misinformation or insufficient education, and a general lack of treatment awareness contribute to a massive underdiagnosis of chronic thromboembolic pulmonary hypertension (CTEPH), diagnostic delay and refusal of surgery by patients. Together with the subjective operability assessment, this leads to too few patients undergoing pulmonary endarterectomy (PEA); even though this surgery results in improved survival and exercise capacity. Acute pulmonary embolism (PE) survivors should undergo a CTEPH screening strategy. Patients screened positive and those with CTEPH symptoms (with or without history of PE), should undergo transthoracic echocardiography (TTE) to determine the probability of PH. High PH probability patients should undergo a ventilation/perfusion (V/Q) scan. A negative scan rules out CTEPH. Patients with a positive V/Q scan, but also patients with findings suggestive for CTEPH on computed tomography pulmonary angiography (CTPA) to diagnose acute PE, should be referred to a CTEPH center. Further diagnostic work-up currently consists of catheter based pulmonary angiography, CTPA and right heart catheterization. However, new imaging technologies might replace them in the near future, with one single imaging tool to screen, diagnose and assess operability as the ultimate goal. Operability assessment should be performed by a multidisciplinary CTEPH team. PEA surgery should be organized in a single center per country or for each forty to fifty million inhabitants in order to offer the highest level of expertise. Informing patients about PEA should preferably be done by the treating surgeon. Based on the estimated incidence of CTEPH and with a better education of patients and healthcare providers, despite the advent of new interventional and medical therapies for CTEPH, the number of PEA surgeries performed should still have the potential to grow significantly.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Laurent Godinas
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Geert Maleux
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Johan Coolen
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Guido Claessen
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Catharina Belge
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marion Delcroix
- Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
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A Novel Doppler TRPG/AcT Index Improves Echocardiographic Diagnosis of Pulmonary Hypertension after Pulmonary Embolism. J Clin Med 2022; 11:jcm11041072. [PMID: 35207345 PMCID: PMC8879629 DOI: 10.3390/jcm11041072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 02/09/2022] [Accepted: 02/13/2022] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We hypothesized that a Doppler index, the ratio of tricuspid regurgitation peak gradient (TRPG) to pulmonary ejection acceleration time (AcT), improves the assessment of the echocardiographic probability of pulmonary hypertension in the identification of CTEPH and chronic thromboembolic pulmonary disease (CTED) in symptomatic patients after PE. Doppler echocardiography is recommended as the initial imaging tool for the diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) after acute pulmonary embolism (PE). METHODS We analyzed the data from 845 consecutive PE (468 women; 61 ± 18 years) survivors who completed at least 6 months of anticoagulation therapy. Here, 555 patients (325 women; 66 ± 16 years) reporting functional impairment (FI) underwent transthoracic echocardiography. We included 506 patients (297 women; age 63.4 ± 16.6 years) in whom both AcT and TRPG were available into the current study. The presence of a minimum of intermediate echocardiographic probability of PH necessitated the diagnosis of CTEPH. RESULTS Echocardiography revealed a high echocardiographic probability of PH in 69 (13.6%) and intermediate echocardiographic probability in 109 (21.5%) patients. CTEPH was diagnosed in 35 (6.9%) patients and CTED in 22 (4.3%) patients. TRPG/AcT was significantly higher in the combined CTEPH + CTED group than in those with other causes of FI (0.412 (0.100-2.197) vs. 0.208 (0.026-0.115), p < 0.001), and the area under the receiver operating characteristic curve of the TRPG/AcT for CTEPH + CTED was 0.804 (95% confidence interval (CI): 0.731-0.876). Importantly, multiple logistic regression showed that TRPG/AcT is a significant predictor of CTEPH + CTED after considering echocardiographic probability (odds ratio = 1.51, 95% CI: 1.25-1.91, p < 0.001). Conditional inference trees analysis revealed that TRPG/AcT > 0.595 identified patients with CTEPH or CTED with a positive predictive value of 78.6% and negative predictive value of 92.7%. CONCLUSIONS A Doppler index TRPG/AcT improves the assessment of symptomatic PE survivors. TRPG/AcT > 0.6 indicates a high probability of CTEPH or CTED, whereas TRPG/AcT < 0.6 allows for the safe exclusion of CTEPH + CTED in patients with a low echocardiographic probability of PH.
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Exciter laser coronary atherectomy (ELCA) can be a powerful weapon in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Med Hypotheses 2022. [DOI: 10.1016/j.mehy.2022.110779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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27
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Ząbczyk M, Natorska J, Janion-Sadowska A, Metzgier-Gumiela A, Polak M, Plens K, Janion M, Skonieczny G, Mizia-Stec K, Undas A. Isoprostane-8 and GDF-15 as novel markers of post-PE syndrome: Relation with prothrombotic factors. Eur J Clin Invest 2022; 52:e13660. [PMID: 34312860 DOI: 10.1111/eci.13660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 06/28/2021] [Accepted: 07/24/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Post-pulmonary embolism (PE) syndrome occurs in up to 50% of PE patients. The pathophysiology of this syndrome is obscure. OBJECTIVE We investigated whether enhanced oxidative stress and prothrombotic state may be involved in post-PE syndrome. METHODS We studied 101 normotensive noncancer PE patients (aged 56.5 ± 13.9 years) on admission, after 5-7 days and after a 3-month anticoagulation, mostly with rivaroxaban. A marker of oxidative stress, 8-isoprostane, endogenous thrombin potential, fibrinolysis proteins, clot lysis time (CLT) and fibrin clot permeability (Ks ), along with PE biomarkers, were determined. RESULTS Patients who developed the post-PE syndrome (n = 31, 30.7%) had at baseline 77.6% higher N-terminal brain natriuretic propeptide and 46.8% higher growth differentiation factor 15, along with 14.1% longer CLT associated with 34.4% higher plasminogen activator inhibitor-1 as compared to subjects without post-PE syndrome (all P < .05). After 5-7 days, only hypofibrinolysis was noted in post-PE syndrome patients. When measured at 3 months, prolonged CLT and reduced Ks were observed in post-PE syndrome patients, accompanied by 23.8% higher growth differentiation factor 15 and 35.8% higher plasminogen activator inhibitor-1 (all P < .05). 8-isoprostane levels ≥108 pg/ml (odds ratio=4.36; 95% confidence interval 1.63-12.27) and growth differentiation factor 15 ≥ 1529 pg/ml (odds ratio=3.89; 95% confidence interval 1.29-12.16) measured at 3 months were associated with higher risk of developing post-PE syndrome. CONCLUSIONS Enhanced oxidative stress and prothrombotic fibrin clot properties could be involved in the pathogenesis of the post-PE syndrome. Elevated growth differentiation factor 15 assessed at 3 months might be a new biomarker of this syndrome.
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Affiliation(s)
- Michał Ząbczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,John Paul II Hospital, Krakow, Poland
| | - Joanna Natorska
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,John Paul II Hospital, Krakow, Poland
| | | | | | - Mateusz Polak
- First Department of Cardiology, Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University, Katowice, Poland
| | | | - Marianna Janion
- Collegium Medicum, The Jan Kochanowski University, Kielce, Poland
| | | | - Katarzyna Mizia-Stec
- First Department of Cardiology, Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University, Katowice, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland.,John Paul II Hospital, Krakow, Poland
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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.
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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.
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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
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Abstract
PURPOSE OF REVIEW In the past decades, the diagnostic and therapeutic management of chronic thromboembolic pulmonary hypertension (CTEPH) has been revolutionized. RECENT FINDINGS Advances in epidemiological knowledge and follow-up studies of pulmonary embolism patients have provided more insight in the incidence and prevalence. Improved diagnostic imaging techniques allow accurate assessment of the location and extend of the thromboembolic burden in the pulmonary artery tree, which is important for the determination of the optimal treatment strategy. Next to the pulmonary endarterectomy, the newly introduced technique percutaneous pulmonary balloon angioplasty and/or P(A)H-targeted medical therapy has been shown to be beneficial in selected patients with CTEPH and might also be of importance in patients with chronic thromboembolic pulmonary vascular disease. SUMMARY In this era of a comprehensive approach to CTEPH with different treatment modalities, a multidisciplinary approach guides management decisions leading to optimal treatment and follow-up of patients with CTEPH.
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Abdel-Razeq H, Ma'koseh M, Mansour A, Bater R, Amarin R, Abufara A, Halahleh K, Manassra M, Alrwashdeh M, Almomani M, Zmaily M. The Application of the ThroLy Risk Assessment Model to Predict Venous Thromboembolism in Patients with Diffuse Large B-Cell Lymphoma. Clin Appl Thromb Hemost 2021; 27:10760296211045908. [PMID: 34590497 PMCID: PMC8642105 DOI: 10.1177/10760296211045908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background Patients with aggressive lymphomas are at higher risk for venous
thromboembolism (VTE). ThroLy is a risk assessment model (RAM) derived to
predict the occurrence of VTE in various types of lymphomas. In this study,
we assess the clinical application of ThroLy RAM in a unified group of
patients with diffuse large B-cell lymphoma (DLBCL). Methods Hospital databases were searched for patients with DLBCL and
radiologically-confirmed VTE. Items in the ThroLy RAM, including prior VTE,
reduced mobility, obesity, extranodal disease, mediastinal involvement,
neutropenia and hemoglobin < 10.0 g/dL, were retrospectively
reviewed. Results A total of 524 patients, median age 49 (range: 18-90) years were included.
Patients had high disease burden; 57.3% with stage III/IV and 34.0% with
bulky disease. All were treated on unified guidelines; 63 (12.0%) had
primary refractory disease. Venous thromboembolic events were reported in 71
(13.5%) patients. Among 121 patients with high (> 3) ThroLy score, 22.3%
developed VTE compared to 8.4% and 12.4% in those with low and intermediate
risk scores, respectively (P = .014). Simplifying the
ThroLy model into two risk groups; high-risk (score ≥ 3) and low risk (score
< 3) can still segregate patients; VTE developed in 44 (17.2%) high-risk
patients (n = 256) compared to 27 (10.1%) in the low-risk
group (n = 268), P = .038. Neutropenia, a
component of the ThroLy, was encountered in only 14 (2.7%) patients. Conclusions ThroLy RAM can identify patients with DLBCL at high risk for VTE. Model can
be modified by dividing patients into two, rather than three risk groups,
and further simplified by omitting neutropenia.
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Affiliation(s)
- Hikmat Abdel-Razeq
- 37559King Hussein Cancer Center, Amman, Jordan.,54658The University of Jordan, Amman, Jordan
| | | | - Asem Mansour
- 37559King Hussein Cancer Center, Department of Radiology, Amman, Jordan
| | - Rayan Bater
- 37559King Hussein Cancer Center, Amman, Jordan
| | - Rula Amarin
- 37559King Hussein Cancer Center, Amman, Jordan
| | | | | | | | | | | | - Mais Zmaily
- 37559King Hussein Cancer Center, Department of Radiology, Amman, Jordan
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Cullivan S, McCormack C, O’Callaghan M, Kevane B, NiAinle F, McCullagh B, Gaine SP. Characteristics of chronic thromboembolic pulmonary hypertension in Ireland. Pulm Circ 2021; 11:20458940211048703. [PMID: 34646498 PMCID: PMC8504238 DOI: 10.1177/20458940211048703] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 09/03/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and under-recognised complication of acute pulmonary embolism. Information regarding the characteristics of CTEPH in Ireland is limited, and the aim of this retrospective cohort study was to address this knowledge gap. Seventy-two cases of CTEPH were diagnosed in the National Pulmonary Hypertension Unit (NPHU) in Ireland between 2010 and 2020. This accounted for 6% of all referrals to the unit and translates to an estimated annual incidence of 1.39 per million population (95% confidence interval, 0.33-2.46). The prevalence of diagnosed CTEPH in Ireland in 2020 was estimated at 12.05 per million population (95% CI 9.00-15.10). The average duration of symptoms prior to CTEPH diagnosis was 23 (±22) months. Patients with CTEPH were more likely to be male (n = 40, 56%), older (60 ± 17 years) and have identifiable risk factors for CTEPH (n = 61, 85%) at diagnosis. Regarding treatment, pulmonary hypertension (PH) vasodilator therapy was prescribed in 75% (n = 54) within 12 months of diagnosis, inferior vena cava filters were placed in 24% (n = 17) and 97% (n = 70) of cases were anticoagulated. Pulmonary endarterectomy was performed in 35% (n = 25), balloon pulmonary angioplasty in 6% (n = 4). One-, three- and five-year survival was 93%, 80% and 65% from the time of diagnosis, and this was significantly better in patients who underwent pulmonary endarterectomy (p = 0.01). This is the first study describing the characteristics of CTEPH in Ireland and highlights suboptimal disease recognition and referral for the assessment for pulmonary endarterectomy.
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Affiliation(s)
- Sarah Cullivan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ciara McCormack
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Marissa O’Callaghan
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Barry Kevane
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala NiAinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Brian McCullagh
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Sean P. Gaine
- National Pulmonary Hypertension Unit, Mater Misericordiae University Hospital, Dublin, Ireland
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Lysenkov SP, Muzhenya DV, Tuguz AR, Urakova TU, Shumilov DS, Thakushinov IA. Participation of nitrogen oxide and its metabolites in the genesis of hyperimmune inflammation in COVID-19. CHINESE J PHYSIOL 2021; 64:167-176. [PMID: 34472447 DOI: 10.4103/cjp.cjp_38_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Despite the success in the tactics of treating COVID-19, there are many unexplored issues related to the development and progression of the process in the lungs, brain, and other organs, as well as the role of individual elements, in particular, nitric oxide (NO), and in the pathogenesis of organ damage. Based on the analyzed literature data, we considered a possible pathophysiological mechanism of action of NO and its derivatives in COVID-19. It can be noted that hyperimmune systemic inflammation and "cytokine storm" are enhanced by the production of NO, products of its oxidation ("nitrosative stress"). It is noted in the work that as a result of the oxidation of NO, a large amount of the toxic compound peroxynitrite is formed, which is a powerful proinflammatory agent. Its presence significantly damages the endothelium of the vascular walls and also oxidizes lipids, hemoglobin, myoglobin, and cytochrome, binds SH-groups of proteins, and damages DNA in the target cells. This is confirmed by the picture of the vessels of the lungs on computed tomography and the data of biochemical studies. In case of peroxynitrite overproduction, inhibition of the synthesis of NO and its metabolic products seems to be justified. Another aspect considered in this work is the mechanism of damage by the virus to the central and peripheral nervous system, which remains poorly understood but may be important in understanding the consequences, as well as predicting brain functions in persons who have undergone COVID-19. According to the analyzed literature, it can be concluded that brain damage is possible due to the direct effect of the virus on the peripheral nerves and central structures, and indirectly through the effect on the endothelium of cerebral vessels. Disturbances in the central nervous regulation of immune responses may be associated with the insufficient function of the acetylcholine anti-inflammatory system. It is proposed to further study several approaches to influence various links of NO exchange, which are of interest for theoretical and practical medicine.
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Affiliation(s)
- Sergey Petrovich Lysenkov
- Department of Pathomorphology and Clinical Pathophysiology, Medical Institute, FSBEI HE "Maikop State Technological University", Maikop, Republic of Adygeya, Russia
| | - Dmitriy Vitalevich Muzhenya
- Department of Pathomorphology and Clinical Pathophysiology, Medical Institute, FSBEI HE "Maikop State Technological University", Maikop, Republic of Adygeya, Russia
| | - Aminat Ramazanovna Tuguz
- Immunogenetic Laboratory of the Research, Institute of Complex Problems, FSBEI HE "Adyghe State University", Maikop, Republic of Adygeya, Russia
| | - Tamara Ur'evna Urakova
- Department of Pathomorphology and Clinical Pathophysiology, Medical Institute, FSBEI HE "Maikop State Technological University", Maikop, Republic of Adygeya, Russia
| | - Dmitriy Sergeevich Shumilov
- Immunogenetic Laboratory of the Research, Institute of Complex Problems, FSBEI HE "Adyghe State University", Maikop, Republic of Adygeya, Russia
| | - Ibragim Askarbievich Thakushinov
- Department of Pathomorphology and Clinical Pathophysiology, Medical Institute, FSBEI HE "Maikop State Technological University", Maikop, Republic of Adygeya, Russia
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Chang Y, Moon JY, Park JH, Choi S, Lee HP, Sim JK, Lee YS. Predictors of residual pulmonary vascular obstruction after anticoagulation monotherapy in patients with intermediate-risk pulmonary embolism. J Thorac Dis 2021; 13:4217-4227. [PMID: 34422350 PMCID: PMC8339779 DOI: 10.21037/jtd-21-403] [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: 03/09/2021] [Accepted: 05/31/2021] [Indexed: 11/19/2022]
Abstract
Background Patients with intermediate-risk pulmonary embolism (PE) can be treated with anticoagulation monotherapy. However, clinicians are concerned as to whether anticoagulation monotherapy is sufficient to reduce mortality in patients with a large embolic burden, and to resolve vascular obstruction. We investigated whether anticoagulation monotherapy was appropriate in patients with intermediate risk PE in terms of the occurrence of residual pulmonary vascular obstruction (RPVO), and the factors that independently predict the occurrence of RPVO. Methods This was a multicenter retrospective observational study of patients at intermediate risk of PE who were admitted to three hospitals between January 2012 and December 2017. Results Of total 91 patients, the median age was 72 years and 37 (40.7%) were male. Twenty-five patients (27.5%) were diagnosed with RPVO during follow-up. Multivariate logistic regression revealed chronic lung disease [odds ratio (OR), 4.14; 95% confidence interval (CI), 1.243–13.797; P=0.021] and the ratio of the diameters of the main pulmonary artery and ascending aorta ratio (P/A ratio) >1.0 documented on a chest computed tomography (CT) at presentation (OR, 3.46; 95% CI, 1.113–10.770; P=0.032) were significant independent predictors of RPVO occurrence. The incidence of RPVO in patients without these two factors was only 9.7%, but in those with the two factors it was 60% (P=0.004). Conclusions Anticoagulation monotherapy did not seem to be a sufficient treatment to reduce RPVO, but the outcome was similar to that of patients treated with other therapies. Therefore, considering the risk-benefit ratio, we do not need to change the initial treatment as systemic thrombolytic therapy or catheter-based therapy in patient with intermediate risk PE. Underlying chronic lung disease and a P/A ratio >1 on the initial chest CT predicted the occurrence of RPVO. Therefore, we should carefully assess persistent of dyspnea and exercise limitations using various methods in patients with these risk factors, to detect the occurrence of chronic thromboembolic pulmonary disease (CTEPD) earlier.
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Affiliation(s)
- Youjin Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Young Moon
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Daejeon, Korea
| | - Jae-Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sangbong Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Hyuk Pyo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jae Kyeom Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
| | - Young Seok Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Seoul, Korea
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Boon GJAM, Janssen SMJ, Barco S, Bogaard HJ, Ghanima W, Kroft LJM, Meijboom LJ, Ninaber MK, Nossent EJ, Spruit MA, Symersky P, Vliegen HW, Noordegraaf AV, Huisman MV, Siegerink B, Abbink JJ, Klok FA. Efficacy and safety of a 12-week outpatient pulmonary rehabilitation program in Post-PE Syndrome. Thromb Res 2021; 206:66-75. [PMID: 34419865 DOI: 10.1016/j.thromres.2021.08.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/11/2021] [Accepted: 08/12/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND The Post-Pulmonary Embolism Syndrome (PPES) comprises heterogeneous entities, including chronic thromboembolic disease with/without pulmonary hypertension (CTEPH/CTEPD), and deconditioning. OBJECTIVES To assess underlying physiological determinants of PPES, and efficacy and safety of rehabilitation training in these patients. METHODS 56 consecutive PE patients with persistent dyspnea and/or functional limitations despite ≥3 months of anticoagulation underwent standardized diagnostic work-up including exercise testing as part of routine practice. All diagnostic (imaging and cardiopulmonary function) tests were interpreted by a core group of experienced clinicians. A subgroup of patients without CTEPH or other treatable conditions was referred for a 12-week personalized rehabilitation program, studying changes in physical condition and patient-reported outcome measures. RESULTS Persistent vascular occlusions were observed in 21/56 patients (38%) and CTEPH was confirmed in ten (18%). Regarding those without CTEPH, impaired cardiopulmonary responses were evident in 18/39 patients with available CPET data (46%), unrelated to chronic thrombi. Rehabilitation was completed by 27 patients after excluding 29 (patients with CTEPH or treatable comorbidities, refusal, ineligibility, or training elsewhere). Training intensity, PE-specific quality of life (PEmb-QoL) and fatigue (CIS) improved with a median difference of 20 W (p = 0.001), 3.9 points (p < 0.001) and 16 points (p = 0.003), respectively. Functional status (Post-VTE Functional Status Scale) improved ≥1 grade in 18 (67%) patients, and declined in one (3.7%). CONCLUSIONS Our findings suggest that abnormal cardiopulmonary responses to exercise are common in patients with PPES and are not limited to those with chronic thrombi. Offering pulmonary rehabilitation to patients not treated otherwise seems safe and promising.
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Affiliation(s)
- Gudula J A M Boon
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz, Germany; Clinic of Angiology, University Hospital of Zurich, Zurich, Switzerland
| | - Harm Jan Bogaard
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Waleed Ghanima
- Departments of Oncology, Medicine and Research, Østfold Hospital Trust, Kalnes, Norway; Institute of Clinical Research, University of Oslo, Oslo, Norway
| | - Lucia J M Kroft
- Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lilian J Meijboom
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Maarten K Ninaber
- Department of Pulmonology, Leiden University Medical Center, Leiden, the Netherlands
| | - Esther J Nossent
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Martijn A Spruit
- Department of Research and Development, CIRO+, Horn, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Faculty of Health, Medicine and Life Sciences, Maastricht, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Petr Symersky
- Department of Cardiac Surgery, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anton Vonk Noordegraaf
- Department of Pulmonology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, VU University Medical Center, Amsterdam, the Netherlands
| | - Menno V Huisman
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands.
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Kaptein F, Stals M, Huisman M, Klok F. Prophylaxis and treatment of COVID-19 related venous thromboembolism. Postgrad Med 2021; 133:27-35. [PMID: 33657964 PMCID: PMC7938649 DOI: 10.1080/00325481.2021.1891788] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/15/2021] [Indexed: 01/08/2023]
Abstract
COVID-19 pneumonia has been associated with high rates of thrombo-embolic complications, mostly venous thromboembolism (VTE), which is thought to be a combination of conventional VTE and in situ immunothrombosis in the pulmonary vascular tree. The incidence of thrombotic complications is dependent on setting (intensive care unit (ICU) versus general ward) and the threshold for performing diagnostic tests (screening versus diagnostic algorithms triggered by symptoms). Since these thrombotic complications are associated with in-hospital mortality, all current guidelines and consensus papers propose pharmacological thromboprophylaxis in all hospitalized patients with COVID-19. Several trials are ongoing to study the optimal intensity of anticoagulation for this purpose. As for the management of thrombotic complications, treatment regimens from non-COVID-19 guidelines can be adapted, with choice of anticoagulant drug class dependent on the situation. Parenteral anticoagulation is preferred for patients on ICUs or with impending clinical deterioration, while oral treatment can be started in stable patients. This review describes current knowledge on incidence and pathophysiology of COVID-19 associated VTE and provides an overview of guideline recommendations on thromboprophylaxis and treatment of established VTE in COVID-19 patients.
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Affiliation(s)
- F.H.J. Kaptein
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M.A.M. Stals
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - M.V. Huisman
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - F.A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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Cao Y, Geng C, Li Y, Zhang Y. In situ Pulmonary Artery Thrombosis: A Previously Overlooked Disease. Front Pharmacol 2021; 12:671589. [PMID: 34305592 PMCID: PMC8296465 DOI: 10.3389/fphar.2021.671589] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/28/2021] [Indexed: 12/30/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is the third leading cause of death in cardiovascular diseases. PTE is believed to be caused by thrombi detached from deep veins of lower extremities. The thrombi travel with systemic circulation to the lung and block pulmonary arteries, leading to sudden disruption of hemodynamics and blood gas exchange. However, this concept has recently been challenged by accumulating evidence demonstrating that de novo thrombosis may be formed in pulmonary arteries without deep venous thrombosis. On the other hand, chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension, could have different pathogenesis than traditional PTE. Therefore, this article summarized and compared the risk factors, the common and specific pathogenic mechanisms underlying PTE, in situ pulmonary artery thrombosis, and CTEPH at molecular and cellular levels, and suggested the therapeutic strategies to these diseases, aiming to facilitate understanding of pathogenesis, differential diagnosis, and precision therapeutics of the three pulmonary artery thrombotic diseases.
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Affiliation(s)
- Yunshan Cao
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Chao Geng
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yahong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Yan Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
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Abstract
PURPOSE OF REVIEW It is now recognized that more than half of patients with acute pulmonary embolism (APE) will have persistent symptoms beyond 3 months after their initial event. Persistent symptoms are referred to as post-PE syndrome, an umbrella term that covers a spectrum of patient complaints and underlying pathologies. Data published over the last 5 years have added significantly to our understanding of this syndrome and its management. RECENT FINDINGS Underlying pathologies linked to post-PE syndrome include chronic thromboembolic pulmonary hypertension (CTEPH), chronic thromboembolic disease (CTED), cardiac dysfunction, and deconditioning. Treatment for post-PE syndrome will depend on the underlying causative pathologies found. Evaluation and treatment for CTEPH is well defined, but less than 10% of patients with post-PE syndrome will qualify as having this diagnosis. SUMMARY A large percentage of patients will experience post-PE syndrome following APE. Strategies for identification and treatment for some pathologies are well studied, but the majority of patients will have subtle abnormalities on imaging and functional testing for which diagnostic criteria and management are not well defined. A number of active studies are designed to help optimize the management of post-PE syndrome and should help us improve intermediate and long-term outcomes for patients following APE.
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Braams NJ, Boon GJAM, de Man FS, van Es J, den Exter PL, Kroft LJM, Beenen LFM, Huisman MV, Nossent EJ, Boonstra A, Vonk Noordegraaf A, Ruigrok D, Klok FA, Bogaard HJ, Meijboom LJ. Evolution of CT findings after anticoagulant treatment for acute pulmonary embolism in patients with and without an ultimate diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 58:13993003.00699-2021. [PMID: 34112733 DOI: 10.1183/13993003.00699-2021] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/13/2021] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The pulmonary arterial morphology of patients with pulmonary embolism (PE) is diverse and it is unclear how the different vascular lesions evolve after initiation of anticoagulant treatment. A better understanding of the evolution of computed tomography pulmonary angiography (CTPA) findings after the start of anticoagulant treatment may help to better identify those PE patients prone to develop chronic thromboembolic pulmonary hypertension (CTEPH). We aimed to assess the evolution of various thromboembolic lesions on CTPA over time after the initiation of adequate anticoagulant treatment in individual acute PE patients with and without an ultimate diagnosis of CTEPH. METHODS We analysed CTPA at diagnosis of acute PE (baseline) and at follow-up in 41 patients with CTEPH and 124 patients without an ultimate diagnosis of CTEPH, all receiving anticoagulant treatment. Central and segmental pulmonary arteries were scored by expert chest radiologists as normal or affected. Lesions were further subclassified as 1) central thrombus, 2) total thrombotic occlusion, 3) mural thrombus, 4) web or 5) tapered pulmonary artery. RESULTS Central thrombi resolved after anticoagulant treatment, while mural thrombi and total thrombotic occlusions either resolved or evolved into webs or tapered pulmonary arteries. Only patients with an ultimate diagnosis of CTEPH exhibited webs and tapered pulmonary arteries on the baseline scan. Moreover, such lesions always persisted after follow-up. CONCLUSIONS Webs and tapered pulmonary arteries at the time of PE diagnosis strongly indicate a state of chronic PE and should raise awareness for possible CTEPH, particularly in patients with persistent dyspnoea after anticoagulant treatment for acute PE.
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Affiliation(s)
- Natalia J Braams
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Gudula J A M Boon
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frances S de Man
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Josien van Es
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Paul L den Exter
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Lucia J M Kroft
- Dept of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ludo F M Beenen
- Dept of Radiology, Amsterdam UMC, AMC, Amsterdam, The Netherlands
| | - Menno V Huisman
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Esther J Nossent
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anco Boonstra
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Dieuwertje Ruigrok
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Frederikus A Klok
- Dept of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Harm Jan Bogaard
- Dept of Pulmonary Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands .,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
| | - Lilian J Meijboom
- Dept of Radiology and Nuclear Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,H.J. Bogaard and L.J. Meijboom are co-last authors and contributed equally to this work
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40
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Chronisch thromboembolische pulmonale Hypertonie. PNEUMO NEWS 2021; 13:33-40. [PMID: 33968267 PMCID: PMC8093596 DOI: 10.1007/s15033-021-2694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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41
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La hipertensión pulmonar secundaria a tromboembolia pulmonar crónica. Una enfermedad en evolución. Rev Esp Cardiol (Engl Ed) 2021. [DOI: 10.1016/j.recesp.2020.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Domingo E, Pérez Hoyos S, Grignola JC. Pulmonary hypertension due to chronic pulmonary thromboembolism. An evolving disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2021; 74:368-370. [PMID: 33509691 DOI: 10.1016/j.rec.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 11/17/2020] [Indexed: 06/12/2023]
Affiliation(s)
- Enric Domingo
- Servei de Cardiologia, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Unitat de Fisiologia Mèdica, Universitat Autònoma de Barcelona, Barcelona, Spain.
| | - Santiago Pérez Hoyos
- Departament de Estadística, Institut de Recerca Hospital Vall d'Hebron, Barcelona, Spain
| | - Juan Carlos Grignola
- Departamento de Fisiopatología, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
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Characterization of a Cohort of Patients with Chronic Thromboembolic Pulmonary Hypertension from Northeastern Colombia (REHINO Study). JOURNAL OF RESPIRATION 2021. [DOI: 10.3390/jor1020012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Chronic thromboembolic disease (CTEPH) is one of the causes for developing pulmonary hypertension (PH). PH is characterized by an increase in pulmonary vascular pressure and resistance, ultimately leading to chronic overload. This study describes the clinical, functional, and hemodynamic characteristics as well as the established treatment strategy for a cohort of patients diagnosed with CTEPH in Bucaramanga, Colombia. In Colombia, PH is considered as an orphan disease with limited epidemiological data. We aim to provide useful information in order to help guide future clinical decisions for PH treatment and prevention. We conducted a cross-sectional study, obtaining clinical data from patients under follow-up, over 18 years of age, with hemodynamic confirmation of CTEPH in two pulmonary outpatient centers in Bucaramanga, Colombia between 2012 and 2018. 35 patients with diagnosis of CTEPH were included. Mean age was 52.3 ± 17.9 years. The mean time between the onset of symptoms to diagnosis was 14 months. 71% had a previous thrombotic event and 69% had functional class III and IV according to the world health organization (WHO) criteria. Most of the patients were classified as at high risk of mortality according to the European Society of Cardiology (ESC) and the European Respiratory Society (ERS/ESC) criteria and 60% were referred to undergo thromboendarterectomy. Most of the patients were under monotherapy treatment with Bosentan, the most prescribed medication in both monotherapy and dual therapy. This study identified a high number of patients in advanced stages of CETPH due to late diagnosis, related to health care limitations. This resulted in worse prognosis and quality of life. In addition, low adherence to non-pharmacological interventions was evidenced in patients who were not candidates for thromboendarterectomy despite the onset of pharmacological therapy.
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Lutchmansingh DD, Knauert MP, Antin-Ozerkis DE, Chupp G, Cohn L, Dela Cruz CS, Ferrante LE, Herzog EL, Koff J, Rochester CL, Ryu C, Singh I, Tickoo M, Winks V, Gulati M, Possick JD. A Clinic Blueprint for Post-Coronavirus Disease 2019 RECOVERY: Learning From the Past, Looking to the Future. Chest 2021; 159:949-958. [PMID: 33159907 PMCID: PMC7641526 DOI: 10.1016/j.chest.2020.10.067] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/04/2020] [Accepted: 10/29/2020] [Indexed: 02/06/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 pandemic poses extraordinary challenges. The tremendous number of coronavirus disease 2019 (COVID-19) cases in the United States has resulted in a large population of survivors with prolonged postinfection symptoms. The creation of multidisciplinary post-COVID-19 clinics to address both persistent symptoms and potential long-term complications requires an understanding of the acute disease and the emerging data regarding COVID-19 outcomes. Experience with severe acute respiratory syndrome and Middle East respiratory syndrome, post-acute respiratory distress syndrome complications, and post-intensive care syndrome also informs anticipated sequelae and clinical program design. Post-COVID-19 clinical programs should be prepared to care for individuals previously hospitalized with COVID-19 (including those who required critical care support), nonhospitalized individuals with persistent respiratory symptoms following COVID-19, and individuals with preexisting lung disease complicated by COVID-19. Effective multidisciplinary collaboration models leverage lessons learned during the early phases of the pandemic to overcome the unique logistical challenges posed by pandemic circumstances. Collaboration between physicians and researchers across disciplines will provide insight into survivorship that may shape the treatment of both acute disease and chronic complications. In this review, we discuss the aims, general principles, elements of design, and challenges of a successful multidisciplinary model to address the needs of COVID-19 survivors.
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Affiliation(s)
- Denyse D. Lutchmansingh
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT,CORRESPONDENCE TO: Denyse D. Lutchmansingh, MBBS
| | - Melissa P. Knauert
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Danielle E. Antin-Ozerkis
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Geoffrey Chupp
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Lauren Cohn
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Charles S. Dela Cruz
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Lauren E. Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Erica L. Herzog
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jonathan Koff
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Carolyn L. Rochester
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - Changwan Ryu
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Inderjit Singh
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Mayanka Tickoo
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Vikki Winks
- Rehabilitation Services, Yale New Haven Hospital/Bridgeport Hospital, Bridgeport, CT
| | - Mridu Gulati
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Jennifer D. Possick
- Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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Habashi NM, Camporota L, Gatto LA, Nieman G. Functional pathophysiology of SARS-CoV-2-induced acute lung injury and clinical implications. J Appl Physiol (1985) 2021; 130:877-891. [PMID: 33444117 PMCID: PMC7984238 DOI: 10.1152/japplphysiol.00742.2020] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/05/2021] [Accepted: 01/07/2021] [Indexed: 02/08/2023] Open
Abstract
The worldwide pandemic caused by the SARS-CoV-2 virus has resulted in over 84,407,000 cases, with over 1,800,000 deaths when this paper was submitted, with comorbidities such as gender, race, age, body mass, diabetes, and hypertension greatly exacerbating mortality. This review will analyze the rapidly increasing knowledge of COVID-19-induced lung pathophysiology. Although controversial, the acute respiratory distress syndrome (ARDS) associated with COVID-19 (CARDS) seems to present as two distinct phenotypes: type L and type H. The "L" refers to low elastance, ventilation/perfusion ratio, lung weight, and recruitability, and the "H" refers to high pulmonary elastance, shunt, edema, and recruitability. However, the LUNG-SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) and ESICM (European Society of Intensive Care Medicine) Trials Groups have shown that ∼13% of the mechanically ventilated non-COVID-19 ARDS patients have the type-L phenotype. Other studies have shown that CARDS and ARDS respiratory mechanics overlap and that standard ventilation strategies apply to these patients. The mechanisms causing alterations in pulmonary perfusion could be caused by some combination of 1) renin-angiotensin system dysregulation, 2) thrombosis caused by loss of endothelial barrier, 3) endothelial dysfunction causing loss of hypoxic pulmonary vasoconstriction perfusion control, and 4) hyperperfusion of collapsed lung tissue that has been directly measured and supported by a computational model. A flowchart has been constructed highlighting the need for personalized and adaptive ventilation strategies, such as the time-controlled adaptive ventilation method, to set and adjust the airway pressure release ventilation mode, which recently was shown to be effective at improving oxygenation and reducing inspiratory fraction of oxygen, vasopressors, and sedation in patients with COVID-19.
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Affiliation(s)
- Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, St Thomas' Hospital, London, United Kingdom
| | - Louis A Gatto
- Department of Surgery, Upstate Medical University, Syracuse, New York
| | - Gary Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York
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46
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Quality of Life 3 and 12 Months Following Acute Pulmonary Embolism: Analysis From a Prospective Multicenter Cohort Study. Chest 2021; 159:2428-2438. [PMID: 33548221 DOI: 10.1016/j.chest.2021.01.071] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 01/11/2021] [Accepted: 01/14/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Few data are available on the long-term course and predictors of quality of life (QoL) following acute pulmonary embolism (PE). RESEARCH QUESTION What are the kinetics and determinants of disease-specific and generic health-related QoL 3 and 12 months following an acute PE? STUDY DESIGN AND METHODS The Follow-up after Acute Pulmonary Embolism (FOCUS) study prospectively followed up consecutive adult patients with objectively diagnosed PE. Patients were considered for study who completed the Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire at predefined visits 3 and 12 months following PE. The course of disease-specific QoL as assessed using the PEmb-QoL and the impact of baseline characteristics using multivariable mixed effects linear regression were studied; also assessed was the course of generic QoL as evaluated by using the EuroQoL Group 5-Dimension 5-Level utility index and the EuroQoL Visual Analog Scale. RESULTS In 620 patients (44% women; median age, 62 years), overall disease-specific QoL improved from 3 to 12 months, with a decrease in the median PEmb-QoL score from 19.4% to 13.0% and a mean individual change of -4.3% (95% CI, -3.2 to -5.5). Female sex, cardiopulmonary disease, and higher BMI were associated with worse QoL at both 3 and 12 months. Over time, the association with BMI became weaker, whereas older age and previous VTE were associated with worsening QoL. Generic QoL also improved: the mean ± SD EuroQoL Group 5-Dimension 5-Level utility index increased from 0.85 ± 0.22 to 0.87 ± 0.20 and the visual analog scale from 72.9 ± 18.8 to 74.4 ± 19.1. INTERPRETATION In a large cohort of survivors of acute PE, the change of QoL was quantified between months 3 and 12 following diagnosis, and factors independently associated with lower QoL and slower recovery of QoL were identified. This information may facilitate the planning and interpretation of clinical trials assessing QoL and help guide patient management. CLINICAL TRIAL REGISTRATION German Clinical Trials Registry (Deutsches Register Klinischer Studien: www.drks.de); No.: DRKS00005939.
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47
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Kruip MJHA, Cannegieter SC, ten Cate H, van Gorp ECM, Juffermans NP, Klok FA, Maas C, Vonk‐Noordegraaf A. Caging the dragon: Research approach to COVID-19-related thrombosis. Res Pract Thromb Haemost 2021; 5:278-290. [PMID: 33733026 PMCID: PMC7938618 DOI: 10.1002/rth2.12470] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 12/18/2022] Open
Abstract
The incidence of venous thrombosis, mostly pulmonary embolism (PE), ranging from local immunothrombosis to central emboli, but also deep vein thrombosis (DVT) in people with coronavirus disease 2019 (COVID-19) is reported to be remarkably high. The relevance of better understanding, predicting, treating, and preventing COVID-19-associated venous thrombosis meets broad support, as can be concluded from the high number of research, review, and guideline papers that have been published on this topic. The Dutch COVID & Thrombosis Coalition (DCTC) is a multidisciplinary team involving a large number of Dutch experts in the broad area of venous thrombosis and hemostasis research, combined with experts on virology, critically ill patients, pulmonary diseases, and community medicine, across all university hospitals and many community hospitals in the Netherlands. Within the consortium, clinical data of at least 5000 admitted COVID-19-infected individuals are available, including substantial collections of biobanked materials in an estimated 3000 people. In addition to considerable experience in preclinical and clinical thrombosis research, the consortium embeds virology-hemostasis research models within unique biosafety facilities to address fundamental questions on the interaction of virus with epithelial and vascular cells, in relation to the coagulation and inflammatory system. The DCTC has initiated a comprehensive research program to answer many of the current questions on the pathophysiology and best anticoagulant treatment of COVID-19-associated thrombotic complications. The research program was funded by grants of the Netherlands Thrombosis Foundation and the Netherlands Organization for Health Research and Development. Here, we summarize the design and main aims of the research program.
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Affiliation(s)
- Marieke J. H. A. Kruip
- Department of HematologyErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Hugo ten Cate
- Maastricht University Medical Center and CARIMMaastrichtThe Netherlands
| | - Eric C. M. van Gorp
- Department of ViroscienceErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
- Department of Infectious DiseasesErasmus MCErasmus University Medical CenterRotterdamThe Netherlands
| | - Nicole P. Juffermans
- Laboratory of Experimental Intensive Care and AnesthesiologyAmsterdam UMC ‐ Location AMCAmsterdamThe Netherlands
- Department of Intensive CareOLVG HospitalAmsterdamThe Netherlands
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and HemostasisLeiden University Medical CenterLeidenThe Netherlands
| | - Coen Maas
- Department of Clinical Chemistry and HematologyUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Anton Vonk‐Noordegraaf
- Dept of Pulmonary MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCVrije Universiteit AmsterdamAmsterdamThe Netherlands
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Dhawan RT, Gopalan D, Howard L, Vicente A, Park M, Manalan K, Wallner I, Marsden P, Dave S, Branley H, Russell G, Dharmarajah N, Kon OM. Beyond the clot: perfusion imaging of the pulmonary vasculature after COVID-19. THE LANCET. RESPIRATORY MEDICINE 2021; 9:107-116. [PMID: 33217366 PMCID: PMC7833494 DOI: 10.1016/s2213-2600(20)30407-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 08/18/2020] [Accepted: 09/01/2020] [Indexed: 12/18/2022]
Abstract
A compelling body of evidence points to pulmonary thrombosis and thromboembolism as a key feature of COVID-19. As the pandemic spread across the globe over the past few months, a timely call to arms was issued by a team of clinicians to consider the prospect of long-lasting pulmonary fibrotic damage and plan for structured follow-up. However, the component of post-thrombotic sequelae has been less widely considered. Although the long-term outcomes of COVID-19 are not known, should pulmonary vascular sequelae prove to be clinically significant, these have the potential to become a public health problem. In this Personal View, we propose a proactive follow-up strategy to evaluate residual clot burden, small vessel injury, and potential haemodynamic sequelae. A nuanced and physiological approach to follow-up imaging that looks beyond the clot, at the state of perfusion of lung tissue, is proposed as a key triage tool, with the potential to inform therapeutic strategies.
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Affiliation(s)
- Ranju T Dhawan
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK; Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK; National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, London, UK; Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Luke Howard
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK; National Pulmonary Hypertension Service, Imperial College Healthcare NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Angelito Vicente
- Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Mirae Park
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Kavina Manalan
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Ingrid Wallner
- Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Peter Marsden
- Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK; Medical Physics and Biomedical Engineering, University College London Hospitals, London, UK
| | - Surendra Dave
- Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Howard Branley
- Respiratory Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Georgina Russell
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK
| | - Nishanth Dharmarajah
- Hybrid Imaging and Therapy Unit, The Wellington Hospital, HCA Healthcare, London, UK
| | - Onn M Kon
- Department of Respiratory Medicine, Imperial College Healthcare NHS Trust, London, UK; National Heart and Lung Institute, Imperial College London, London, UK
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Matusov Y, Singh I, Yu YR, Chun HJ, Maron BA, Tapson VF, Lewis MI, Rajagopal S. Chronic Thromboembolic Pulmonary Hypertension: the Bedside. Curr Cardiol Rep 2021; 23:147. [PMID: 34410530 PMCID: PMC8375459 DOI: 10.1007/s11886-021-01573-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Chronic thromboembolic pulmonary hypertension (CTEPH), included in group 4 PH, is an uncommon complication of acute pulmonary embolism (PE), in which emboli in the pulmonary vasculature do not resolve but rather form into an organized scar-like obstruction which can result in right ventricular (RV) failure. Here we provide an overview of current diagnosis and management of CTEPH. RECENT FINDINGS CTEPH management is complex with treatments that range from surgery, percutaneous interventions, to medical therapies. Current CTEPH medical therapies have largely been repurposed from pulmonary arterial hypertension (PAH). The diagnosis of CTEPH can be challenging, requiring a multimodality approach to differentiate from disease mimics. While these treatments improve symptoms, they may not reverse the underlying pathology of CTEPH.
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Affiliation(s)
- Yuri Matusov
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Inderjit Singh
- grid.47100.320000000419368710Division of Pulmonary, Critical Care, and Sleep Medicine, Yale New Haven Hospital and Yale School of Medicine, New Haven, CT USA
| | - Yen-Rei Yu
- grid.189509.c0000000100241216Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC USA
| | - Hyung J. Chun
- grid.47100.320000000419368710Section of Cardiovascular Medicine, Department of Internal Medicine, Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, CT USA
| | - Bradley A. Maron
- grid.410370.10000 0004 4657 1992Section of Cardiology, Veterans Affairs Boston Healthcare System, Boston, MA USA ,grid.62560.370000 0004 0378 8294Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Victor F. Tapson
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Michael I. Lewis
- grid.50956.3f0000 0001 2152 9905Division of Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA USA
| | - Sudarshan Rajagopal
- grid.189509.c0000000100241216Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC USA
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50
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Boon GJ, Huisman MV, Klok FA. Why, Whom, and How to Screen for Chronic Thromboembolic Pulmonary Hypertension after Acute Pulmonary Embolism. Semin Thromb Hemost 2020; 47:692-701. [DOI: 10.1055/s-0040-1718925] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
AbstractChronic thromboembolic pulmonary hypertension (CTEPH) is considered a long-term complication of acute pulmonary embolism (PE). Diagnosing CTEPH is challenging, as demonstrated by a considerable diagnostic delay exceeding 1 year, which has a negative impact on the patient's prognosis. Dedicated screening CTEPH strategies in PE survivors could potentially help diagnosing CTEPH earlier, although the optimal strategy is unknown. Recently published updated principles for screening in medicine outline the conditions that must be considered before implementation of a population-based screening program. Following these extensive principles, we discuss the pros and cons of CTEPH screening, touching on the epidemiology of CTEPH, the prognosis of CTEPH in the perspective of emerging treatment possibilities, and potentially useful tests and test combinations for screening. This review provides a modern perspective on CTEPH screening including a novel approach using a simple noninvasive algorithm of sequential diagnostic tests applied to all PE survivors.
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Affiliation(s)
- Gudula J.A.M. Boon
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V. Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A. Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
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