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Zhang S, Li Y, Yang Y, Gong S, Yang Z, Hong C, Cui X, Wan J, Ji Y, Chen H, Zhu L, Li C, Cheng Z, Zhang Y, Wang Q, Luo Q, Guo L, Ma G, Han B, Liu Z, Xiong C, Wang L, Ji Q, Li F, Wang S, Zhang Z, Zhang Y, Wang D, Gao Q, Huang Q, Xie W, Zhai Z, Wang C. The management pattern and outcomes of chronic thromboembolic pulmonary hypertension: rationale and design for a Chinese real-world study. BMC Pulm Med 2024; 24:265. [PMID: 38825688 PMCID: PMC11145764 DOI: 10.1186/s12890-024-03042-5] [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: 04/18/2024] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive pulmonary vascular disorder with substantial morbidity and mortality, also a disease underdiagnosed and undertreated. It is potentially curable by pulmonary endarterectomy (PEA) in patients with surgically accessible thrombi. Balloon pulmonary angioplasty (BPA) and targeted medical therapy are options for patients with distal lesions or persistent/recurrent pulmonary hypertension after PEA. There is an urgent need to increase the awareness of CTEPH. Qualified CTEPH centers are still quite limited. Baseline characteristics, management pattern and clinical outcome of CTEPH in China needs to be reported. METHODS AND DESIGN The CHinese reAl-world study to iNvestigate the manaGEment pattern and outcomes of chronic thromboembolic pulmonary hypertension (CHANGE) study is designed to provide the multimodality treatment pattern and clinical outcomes of CTEPH in China. Consecutive patients who are ≥ 14 year-old and diagnosed with CTEPH are enrolled. The diagnosis of CTEPH is confirmed in right heart catheterization and imaging examinations. The multimodality therapeutic strategy, which consists of PEA, BPA and targeted medical therapy, is made by a multidisciplinary team. The blood sample and tissue from PEA are stored in the central biobank for further research. The patients receive regular follow-up every 3 or 6 months for at least 3 years. The primary outcomes include all-cause mortality and changes in functional and hemodynamic parameters from baseline. The secondary outcomes include the proportion of patients experiencing lung transplantation, the proportion of patients experiencing heart and lung transplantation, and changes in health-related quality of life. Up to 31 December 2023, the study has enrolled 1500 eligible patients from 18 expert centers. CONCLUSIONS As a real-world study, the CHANGE study is expected to increase our understanding of CTEPH, and to fill the gap between guidelines and the clinical practice in the diagnosis, assessment and treatment of patients with CTEPH. REGISTRATION NUMBER IN CLINICALTRIALS.GOV: NCT05311072.
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Affiliation(s)
- Shuai Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yishan Li
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chaoyang Hospital, Capital Medical University, Beijing, P.R. China
| | - Sugang Gong
- Dpartments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Zhenwen Yang
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, P.R. China
| | - Cheng Hong
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, P.R. China
| | - Xiaopei Cui
- Department of Geriatric Medicine, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Jun Wan
- Department of Pulmonary and Critical Care Medicine, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. China
| | - Yingqun Ji
- Department of Pulmonary and Critical Care Medicine, East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hong Chen
- Department of Pulmonary and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Ling Zhu
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, P.R. China
| | - Chenghong Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Zhaozhong Cheng
- Department of Pulmonary and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong Province, P.R. China
| | - Yunhui Zhang
- Department of Respiratory Medicine, The First People's Hospital of Yunnan Province, Kunming, P.R. China
| | - Qiguang Wang
- Division of Pulmonary Vascular Disease, General Hospital of Northern Theater of Command, Shenyang, P.R. China
| | - Qin Luo
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lu Guo
- Department of Pulmonary and Critical Care Medicine, School of Medicine, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, P.R. China
| | - Guofeng Ma
- Department of Respiratory Diseases, Sir Run Run ShawHospital, Zhejiang University School of Medicine, Hangzhou, P.R. China
| | - Baoshi Han
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, P.R. China
| | - Zhihong Liu
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Changming Xiong
- Center for Pulmonary Vascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Lan Wang
- Departments of Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, P.R. China
| | - Qiushang Ji
- Department of Cardiology, Qilu Hospital of Shandong University, Jinan, P.R. China
| | - Fajiu Li
- Department of Pulmonary and Critical Care Medicine, Affiliated Hospital of Jianghan University, Wuhan, P.R. China
| | - Shengfeng Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, P.R. China
| | - Zhu Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Yunxia Zhang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Dingyi Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Data and Project Management Unit, Institute of Clinical Medical Sciences, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qian Gao
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Qiang Huang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
| | - Wanmu Xie
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Zhenguo Zhai
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China.
| | - Chen Wang
- National Center for Respiratory Medicine, State Key Laboratory of Respiratory Health and Multimorbidity, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, Chinese Academy of Medical Sciences, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, P.R. China
- Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, P.R. China
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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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Kayali SM, Dietz BE, Siddiq BS, Ghaly M, Owens TS, Khouzam RN. Chronic thromboembolic pulmonary hypertension and balloon pulmonary angioplasty - Where are we in 2024? Curr Probl Cardiol 2024; 49:102481. [PMID: 38401824 DOI: 10.1016/j.cpcardiol.2024.102481] [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: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 02/26/2024]
Abstract
Pulmonary endarterectomy (PEA) is the first-line treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, some patients with CTEPH are considered inoperable, and in the last decade, balloon pulmonary angioplasty (BPA) has emerged as a viable therapeutic option for these patients with prohibitive surgical risk or recurrent pulmonary hypertension following PEA. Numerous international centers have increased their procedural volume of BPA and have reported improvements in pulmonary hemodynamics, patient functional class and right ventricular function. Randomized controlled trials have also demonstrated similar findings. Recent refinements in procedural technique, increased operator experience and advancements in procedural technology have facilitated marked reduction in the risk of complications following BPA. Current guidelines recommend BPA for patients with inoperable CTEPH and persistent pulmonary hypertension following PEA. The pulmonary arterial endothelium plays a vital role in the pathophysiologic development and progression of CTEPH.
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Affiliation(s)
- Sharif M Kayali
- University of Tennessee Health Sciences Center, Department of Cardiovascular Medicine, Memphis, TN.
| | - Bernhard E Dietz
- University of Tennessee Health Sciences Center, Department of Internal Medicine, Memphis, TN
| | - Bilal S Siddiq
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Michael Ghaly
- Baptist Memorial Hospital - North Mississippi, Department of Internal Medicine, Oxford, MS
| | - Timothy S Owens
- University of Tennessee Health Sciences Center, College of Medicine, Memphis, TN
| | - Rami N Khouzam
- Interventional Cardiologist at the Grand Strand Medical Center, Myrtle Beach, SC; Professor, School of Medicine, University of South Carolina, Columbia SC; Professor, Edward Via College of Osteopathic Medicine, Blacksburg, VA; Professor, at the Mercer School of Medicine, Savannah, GA; Professor, University of Tennessee College of Medicine, Memphis, TN
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4
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Gertz RJ, Gerhardt F, Pienn M, Lennartz S, Kröger JR, Caldeira L, Pennig L, Schömig TH, Hokamp NG, Maintz D, Rosenkranz S, Bunck AC. Dual-layer dual-energy CT-derived pulmonary perfusion for the differentiation of acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eur Radiol 2024; 34:2944-2956. [PMID: 37921925 PMCID: PMC11126515 DOI: 10.1007/s00330-023-10337-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 09/18/2023] [Accepted: 10/03/2023] [Indexed: 11/05/2023]
Abstract
OBJECTIVES To evaluate dual-layer dual-energy computed tomography (dlDECT)-derived pulmonary perfusion maps for differentiation between acute pulmonary embolism (PE) and chronic thromboembolic pulmonary hypertension (CTEPH). METHODS This retrospective study included 131 patients (57 patients with acute PE, 52 CTEPH, 22 controls), who underwent CT pulmonary angiography on a dlDECT. Normal and malperfused areas of lung parenchyma were semiautomatically contoured using iodine density overlay (IDO) maps. First-order histogram features of normal and malperfused lung tissue were extracted. Iodine density (ID) was normalized to the mean pulmonary artery (MPA) and the left atrium (LA). Furthermore, morphological imaging features for both acute and chronic PE, as well as the combination of histogram and morphological imaging features, were evaluated. RESULTS In acute PE, normal perfused lung areas showed a higher mean and peak iodine uptake normalized to the MPA than in CTEPH (both p < 0.001). After normalizing mean ID in perfusion defects to the LA, patients with acute PE had a reduced average perfusion (IDmean,LA) compared to both CTEPH patients and controls (p < 0.001 for both). IDmean,LA allowed for a differentiation between acute PE and CTEPH with moderate accuracy (AUC: 0.72, sensitivity 74%, specificity 64%), resulting in a PPV and NPV for CTEPH of 64% and 70%. Combining IDmean,LA in the malperfused areas with the diameter of the MPA (MPAdia) significantly increased its ability to differentiate between acute PE and CTEPH (sole MPAdia: AUC: 0.76, 95%-CI: 0.68-0.85 vs. MPAdia + 256.3 * IDmean,LA - 40.0: AUC: 0.82, 95%-CI: 0.74-0.90, p = 0.04). CONCLUSION dlDECT enables quantification and characterization of pulmonary perfusion patterns in acute PE and CTEPH. Although these lack precision when used as a standalone criterion, when combined with morphological CT parameters, they hold potential to enhance differentiation between the two diseases. CLINICAL RELEVANCE STATEMENT Differentiating between acute PE and CTEPH based on morphological CT parameters is challenging, often leading to a delay in CTEPH diagnosis. By revealing distinct pulmonary perfusion patterns in both entities, dlDECT may facilitate timely diagnosis of CTEPH, ultimately improving clinical management. KEY POINTS • Morphological imaging parameters derived from CT pulmonary angiography to distinguish between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension lack diagnostic accuracy. • Dual-layer dual-energy CT reveals different pulmonary perfusion patterns between acute pulmonary embolism and chronic thromboembolic pulmonary hypertension. • The identified parameters yield potential to enable more timely identification of patients with chronic thromboembolic pulmonary hypertension.
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Affiliation(s)
- Roman Johannes Gertz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.
| | - Felix Gerhardt
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Michael Pienn
- Ludwig Boltzmann Institute for Lung Vascular Research, Graz, Austria
| | - Simon Lennartz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jan Robert Kröger
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr University Bochum, Johannes Wesling University Hospital, Bochum, Germany
| | - Liliana Caldeira
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lenhard Pennig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Thomas Henning Schömig
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nils Große Hokamp
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - David Maintz
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephan Rosenkranz
- Department of Cardiology, Heart Center, Faculty of Medicine, University of Cologne, Cologne, Germany
| | - Alexander Christian Bunck
- Department of Radiology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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Ullalkar N, M V, Pn S, Vaibhavi D, Ca S. To Compare the Effectiveness of Low-Molecular-Weight Heparin and Unfractionated Heparin in Reducing Lower Limb Girth in Deep Vein Thrombosis. Cureus 2024; 16:e59449. [PMID: 38827007 PMCID: PMC11141321 DOI: 10.7759/cureus.59449] [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] [Accepted: 05/01/2024] [Indexed: 06/04/2024] Open
Abstract
INTRODUCTION Treating deep vein thrombosis (DVT) using a once-daily dose of enoxaparin offers greater convenience and the possibility of home-based care for certain patients, as opposed to a continuous infusion of unfractionated heparin (UFH). The study aimed to determine the most cost-effective thromboprophylaxis between low-molecular-weight heparin (LMWH) and UFH for hospitalized patients. MATERIALS AND METHODS After obtaining clearance from the institutional ethical committee, the study was conducted in the Department of General Surgery, Sri Devaraj Urs Medical College, over a period of six months. Informed consent was obtained from all 46 patients included in this study. The participants were divided into two groups: group A received LMWH and group B received UFH. RESULTS The mean age in group A was 59.8 + 10.6 years and in group B was 54.9 + 12.3 years. There was no significant difference in the girth of the lower limb between the groups during the follow-up period (p > 0.05). In group A, there was a highly significant reduction in lower limb girth from day one to day five (p < 0.0001), day five to day 10 (p < 0.0001), and day one to day 10 (p < 0.0001). In group B, there was no significant reduction from day one to day five (p = 0.06), but there was a significant reduction from day five to day 10 (p = 0.001) and day one to day 10 (p = 0.001). CONCLUSION Treatment with LMWH as an anticoagulant significantly reduced the lower extremity girth and thrombus thickness in cases of DVT when compared to UFH.
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Affiliation(s)
- Neha Ullalkar
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Vedanth M
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Sreeramulu Pn
- Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - D Vaibhavi
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
| | - Shashirekha Ca
- General Surgery, Sri Devaraj Urs Medical College, Kolar, IND
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Trammell AW, Ball J. Accumulating Evidence for Reduced-Dose Thrombolysis in Acute Pulmonary Embolism. Crit Care Med 2024; 52:847-850. [PMID: 38619343 DOI: 10.1097/ccm.0000000000006206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
- Aaron W Trammell
- Pulmonary, Allergy, Critical Care, and Sleep Medicine Division, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jonathan Ball
- General Intensive Care Unit, St George's Hospital, London, United Kingdom
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Lio KU, Bashir R, Lakhter V, Li S, Panaro J, Rali P. Impact of reperfusion therapies on clot resolution and long-term outcomes in patients with pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101823. [PMID: 38369293 DOI: 10.1016/j.jvsv.2024.101823] [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: 11/20/2023] [Revised: 12/23/2023] [Accepted: 12/28/2023] [Indexed: 02/20/2024]
Abstract
OBJECTIVE Major progress in reperfusion strategies has substantially improved the short-term outcomes of patients with pulmonary embolism (PE), however, up to 50% of patients report persistent dyspnea after acute PE. METHODS A retrospective study of the PE response team registry and included patients with repeat imaging at 3 to 12 months. The primary outcome was to determine the incidence of residual pulmonary vascular obstruction following acute PE. Secondary outcomes included the development of PE recurrence, right ventricular (RV) dysfunction, chronic thromboembolic pulmonary hypertension, readmission, and mortality at 12 months. RESULTS A total of 382 patients were included, and 107 patients received reperfusion therapies followed by anticoagulation. Patients who received reperfusion therapies including systemic thrombolysis, catheter-directed thrombolysis, and mechanical thrombectomy presented with a higher vascular obstructive index (47% vs 28%; P < .001) and signs of right heart strain on echocardiogram (81% vs 43%; P < .001) at the time of diagnosis. A higher absolute reduction in vascular obstructive index (45% vs 26%; 95% confidence interval, 14.0-25.6; P < .001), greater improvement in RV function (82% vs 65%; P = .021), and lower 12-month mortality rate (2% vs 7%; P = .038) and readmission rate (33% vs 46%; P = .031) were observed in the reperfusion group. No statistically significant differences were found between groups in the development of chronic thromboembolic pulmonary hypertension (8% vs 5%; P = .488) and PE recurrence (8% vs 6%; P = .646). CONCLUSIONS We observed a favorable survival and greater improvement in clot resolution and RV function in patients treated with reperfusion therapies.
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Affiliation(s)
- Ka U Lio
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA.
| | - Riyaz Bashir
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Vladimir Lakhter
- Division of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Si Li
- Department of Medicine, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Joseph Panaro
- Department of Radiology, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Ley L, Messmer F, Vaisnora L, Ghofrani HA, Bandorski D, Kostrzewa M. Electrocardiographic Changes after Endovascular Mechanical Thrombectomy in a Patient with Pulmonary Embolism-A Case Report and Literature Review. J Clin Med 2024; 13:2548. [PMID: 38731076 PMCID: PMC11084833 DOI: 10.3390/jcm13092548] [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: 03/05/2024] [Revised: 03/24/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Background: Pulmonary embolism (PE) is a common disease with an annual incidence of about 1/1000 persons. About every sixth patient dies within the first 30 days after diagnosis. The electrocardiogram (ECG) is one of the first diagnostic tests performed, and is able to confirm the suspicion of PE with typical electrocardiographic signs. Some ECG signs and their regression are also prognostically relevant. Endovascular mechanical thrombectomy is one option for PE treatment, and aims to relieve right heart strain immediately. The first studies on endovascular mechanical thrombectomy using a dedicated device (FlowTriever System, Inari Medical, Irvine, CA, USA) yielded promising results. Methods: In the following, we report the case of a 66-year-old male patient who presented with New York Heart Association III dyspnea in our emergency department. Among typical clinical and laboratory results, he displayed very impressive electrocardiographic and radiological findings at the time of PE diagnosis. Results: After endovascular mechanical thrombectomy, the patient's complaints and pulmonary hemodynamics improved remarkably. In contrast, the ECG worsened paradoxically 18 h after intervention. Nevertheless, control echocardiography 4 days after the intervention no longer showed any signs of right heart strain, and dyspnea had disappeared completely. At a 4-month follow-up visit, the patient presented as completely symptom-free with a high quality of life. His ECG and echocardiography were normal and excluded recurrent right heart strain. Conclusions: Overall, the patient benefitted remarkably from endovascular mechanical thrombectomy, resulting in an almost complete resolution of electrocardiographic PE signs at the 4-month follow-up after exhibiting multiple typical electrocardiographic PE signs at time of diagnosis and initial electrocardiographic worsening 18 h post successful intervention.
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Affiliation(s)
- Lukas Ley
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
- Campus Kerckhoff, Justus-Liebig-University Giessen, 61231 Bad Nauheim, Germany
| | - Florian Messmer
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
| | - Lukas Vaisnora
- Department of Cardiology, Baden Cantonal Hospital, 5404 Baden, Switzerland;
| | | | - Dirk Bandorski
- Faculty of Medicine, Semmelweis University Campus Hamburg, 20099 Hamburg, Germany;
| | - Michael Kostrzewa
- Department of Radiology, Baden Cantonal Hospital, 5404 Baden, Switzerland; (F.M.); (M.K.)
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Zhang D, Fu W, Zhu S, Pan Y, Li R. RNA methylation patterns, immune characteristics, and autophagy-related mechanisms mediated by N6-methyladenosine (m6A) regulatory factors in venous thromboembolism. BMC Genomics 2024; 25:403. [PMID: 38658847 PMCID: PMC11044431 DOI: 10.1186/s12864-024-10294-2] [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: 03/08/2024] [Accepted: 04/09/2024] [Indexed: 04/26/2024] Open
Abstract
Recent studies have found a link between deep vein thrombosis and inflammatory reactions. N6-methyladenosine (m6A), a crucial element in immunological regulation, is believed to contribute to the pathophysiology of venous thromboembolism (VTE). However, how the m6A-modified immune microenvironment is involved in VTE remains unclear. In the present study, we identified a relationship between VTE and the expression of several m6A regulatory elements by analyzing peripheral blood samples from 177 patients with VTE and 88 healthy controls from public GEO databases GSE19151 and GSE48000. We used machine learning to identify essential genes and constructed a diagnostic model for VTE using multivariate logistic regression. Unsupervised cluster analysis revealed a marked difference between m6A modification patterns in terms of immune cell infiltration, inflammatory reactivity, and autophagy. We identified two m6A-related autophagy genes (i.e., CHMP2B and SIRT1) and the crucial m6A regulator YTHDF3 using bioinformatics. We also examined two potential mechanisms through which YTHDF3 may affect VTE. m6A modification, immunity, and autophagy are closely linked in VTE, offering novel mechanistic and therapeutic insights.
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Affiliation(s)
| | - Wenxia Fu
- Shanghai Chest Hospital, Shanghai, 200030, China
| | - Shiwei Zhu
- Shanghai Chest Hospital, Shanghai, 200030, China
| | - Yitong Pan
- Shanghai Chest Hospital, Shanghai, 200030, China
| | - Ruogu Li
- Shanghai Chest Hospital, Shanghai, 200030, China.
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10
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Aggarwal V, Giri J, Visovatti SH, Mahmud E, Matsubara H, Madani M, Rogers F, Gopalan D, Rosenfield K, McLaughlin VV. Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1090-e1107. [PMID: 38450477 DOI: 10.1161/cir.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.
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11
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Vohra AS, Olonoff DA, Ip A, Kirtane AJ, Steinberg Z, Horn E, Krishnan U, Reisman M, Bergman G, Wong S, Feldman DN, Kim LK, Singh HS. Nationwide trends of balloon pulmonary angioplasty and pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (2012-2019). Pulm Circ 2024; 14:e12374. [PMID: 38736894 PMCID: PMC11082429 DOI: 10.1002/pul2.12374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 03/03/2024] [Accepted: 03/19/2024] [Indexed: 05/14/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes.
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Affiliation(s)
- Adam S. Vohra
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | | | - Ada Ip
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Ajay J. Kirtane
- Department of Medicine, Division of CardiologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Zachary Steinberg
- Department of Medicine, Division of CardiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Evelyn Horn
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Udhay Krishnan
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Mark Reisman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Geoffrey Bergman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Shing‐Chiu Wong
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Dmitriy N. Feldman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Luke K. Kim
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Harsimran S. Singh
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
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12
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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S. Estimating the value of future research into thromboprophylaxis for women during pregnancy and after delivery: a value of information analysis. J Thromb Haemost 2024; 22:1105-1116. [PMID: 38215911 DOI: 10.1016/j.jtha.2023.12.035] [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: 09/20/2023] [Revised: 12/28/2023] [Accepted: 12/30/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Risk assessment models (RAMs) are used to select women at increased risk of venous thromboembolism (VTE) during pregnancy and the puerperium for thromboprophylaxis. OBJECTIVES To estimate the value of potential future studies that would reduce the decision uncertainty associated with offering thromboprophylaxis according to available RAMs in the following groups: high-risk antepartum women (eg, prior VTE), unselected postpartum women, and postpartum women with risk factors (obesity or cesarean delivery). METHODS A decision-analytic model was developed to simulate clinical outcomes, lifetime costs, and quality-adjusted life-years for different thromboprophylaxis strategies, including thromboprophylaxis for all, thromboprophylaxis for none, and RAM-based thromboprophylaxis. The expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty. The value of future research studies was estimated using expected value of sample information analysis. Costs were assessed from a health and social services perspective. RESULTS The expected value of perfect information analysis identified high decision uncertainty for high-risk antepartum women (£21.8 million) and obese postpartum women (£13.4 million), which was largely attributable to uncertainty regarding the effectiveness of thromboprophylaxis in reducing VTE. A randomized controlled trial of thromboprophylaxis compared with none in obese postpartum women is likely to have substantial value (£2.8 million; 300 participants per arm). A trial in women with previous VTE would have higher value but would be less acceptable. CONCLUSION Future research should focus on estimating the effectiveness of thromboprophylaxis in obese postpartum women with additional risk factors who have not had a previous VTE.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom.
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Fiona C Sampson
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Jean Hamilton
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Catherine Nelson-Piercy
- Women's Health Academic Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre, Guy's and St Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Jahnavi Daru
- Institute of Population Health, Queen Mary University of London, London, United Kingdom
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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13
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Horner DE, Davis S, Pandor A, Shulver H, Goodacre S, Hind D, Rex S, Gillett M, Bursnall M, Griffin X, Holland M, Hunt BJ, de Wit K, Bennett S, Pierce-Williams R. Evaluation of venous thromboembolism risk assessment models for hospital inpatients: the VTEAM evidence synthesis. Health Technol Assess 2024; 28:1-166. [PMID: 38634415 PMCID: PMC11056814 DOI: 10.3310/awtw6200] [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: 04/19/2024] Open
Abstract
Background Pharmacological prophylaxis during hospital admission can reduce the risk of acquired blood clots (venous thromboembolism) but may cause complications, such as bleeding. Using a risk assessment model to predict the risk of blood clots could facilitate selection of patients for prophylaxis and optimise the balance of benefits, risks and costs. Objectives We aimed to identify validated risk assessment models and estimate their prognostic accuracy, evaluate the cost-effectiveness of different strategies for selecting hospitalised patients for prophylaxis, assess the feasibility of using efficient research methods and estimate key parameters for future research. Design We undertook a systematic review, decision-analytic modelling and observational cohort study conducted in accordance with Enhancing the QUAlity and Transparency Of health Research (EQUATOR) guidelines. Setting NHS hospitals, with primary data collection at four sites. Participants Medical and surgical hospital inpatients, excluding paediatric, critical care and pregnancy-related admissions. Interventions Prophylaxis for all patients, none and according to selected risk assessment models. Main outcome measures Model accuracy for predicting blood clots, lifetime costs and quality-adjusted life-years associated with alternative strategies, accuracy of efficient methods for identifying key outcomes and proportion of inpatients recommended prophylaxis using different models. Results We identified 24 validated risk assessment models, but low-quality heterogeneous data suggested weak accuracy for prediction of blood clots and generally high risk of bias in all studies. Decision-analytic modelling showed that pharmacological prophylaxis for all eligible is generally more cost-effective than model-based strategies for both medical and surgical inpatients, when valuing a quality-adjusted life-year at £20,000. The findings were more sensitive to uncertainties in the surgical population; strategies using risk assessment models were more cost-effective if the model was assumed to have a very high sensitivity, or the long-term risks of post-thrombotic complications were lower. Efficient methods using routine data did not accurately identify blood clots or bleeding events and several pre-specified feasibility criteria were not met. Theoretical prophylaxis rates across an inpatient cohort based on existing risk assessment models ranged from 13% to 91%. Limitations Existing studies may underestimate the accuracy of risk assessment models, leading to underestimation of their cost-effectiveness. The cost-effectiveness findings do not apply to patients with an increased risk of bleeding. Mechanical thromboprophylaxis options were excluded from the modelling. Primary data collection was predominately retrospective, risking case ascertainment bias. Conclusions Thromboprophylaxis for all patients appears to be generally more cost-effective than using a risk assessment model, in hospitalised patients at low risk of bleeding. To be cost-effective, any risk assessment model would need to be highly sensitive. Current evidence on risk assessment models is at high risk of bias and our findings should be interpreted in this context. We were unable to demonstrate the feasibility of using efficient methods to accurately detect relevant outcomes for future research. Future work Further research should evaluate routine prophylaxis strategies for all eligible hospitalised patients. Models that could accurately identify individuals at very low risk of blood clots (who could discontinue prophylaxis) warrant further evaluation. Study registration This study is registered as PROSPERO CRD42020165778 and Researchregistry5216. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127454) and will be published in full in Health Technology Assessment; Vol. 28, No. 20. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Daniel Edward Horner
- Emergency Department, Northern Care Alliance NHS Foundation Trust, Salford, UK
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Oxford Road, Manchester, UK
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Helen Shulver
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel Hind
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michael Gillett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Bursnall
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Xavier Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Beverley Jane Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, King's Healthcare Partners, London, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queens University, Kingston, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Shan Bennett
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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14
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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15
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Wang Y, Zhao S, Lu M. State-of-the Art Cardiac Magnetic Resonance in Pulmonary Hypertension - An Update on Diagnosis, Risk Stratification and Treatment. Trends Cardiovasc Med 2024; 34:161-171. [PMID: 36574866 DOI: 10.1016/j.tcm.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 11/13/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Abstract
Pulmonary hypertension (PH) is a globally under-recognized but life-shortening disease with a poor prognosis if untreated, delayed or inappropriately treated. One of the most important issues for PH is to improve patient quality of life and survival through timely and accurate diagnosis, precise risk stratification and prognosis prediction. Cardiac magnetic resonance (CMR), a non-radioactive, non-invasive image-based examination with excellent tissue characterization, provides a comprehensive assessment of not only the disease severity but also secondary changes in cardiac structure, function and tissue characteristics. The purpose of this review is to illustrate an updated status of CMR for PH assessment, focusing on the application of both conventional and emerging technologies as well as the latest clinical trials.
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Affiliation(s)
- Yining Wang
- Department of Magnetic Resonance Imaging, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing 100037, China
| | - Shihua Zhao
- Department of Magnetic Resonance Imaging, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing 100037, China
| | - Minjie Lu
- Department of Magnetic Resonance Imaging, Fuwai Hospital, State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, No.167, Beilishi Road, Xicheng District, Beijing 100037, China; Key Laboratory of Cardiovascular Imaging (Cultivation), Chinese Academy of Medical Sciences, Beijing, China.
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16
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Krigere A, Kalejs VR, Kaulins R, Rudzitis A, Bondare L, Sablinskis M, Lejnieks A, Kigitovica D, Kurzyna M, Skride A. The Initial Experience of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension in Latvia. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:568. [PMID: 38674214 PMCID: PMC11052274 DOI: 10.3390/medicina60040568] [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: 01/14/2024] [Revised: 03/21/2024] [Accepted: 03/27/2024] [Indexed: 04/28/2024]
Abstract
Background: Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) or persistent pulmonary hypertension after pulmonary endarterectomy (PEA) include targeted medical therapy and balloon pulmonary angioplasty (BPA). BPA is an emerging treatment modality that has been reported to improve functional capacity, pulmonary hemodynamics, and right ventricular function. Reports from expert centers are promising, but more data are needed to make the results more generalizable. Materials and Methods: We conducted a prospective analysis of nine consecutive CTEPH patients who underwent balloon pulmonary angioplasty (BPA) sessions at Pauls Stradins Clinical University Hospital in Riga, Latvia between 1 April 2022 and 1 July 2023. We assessed World Health Organization (WHO) functional class, 6 min walk distance (6MWD), blood oxygen saturation (SpO2), brain natriuretic peptide (BNP) level at baseline and 3 months after the first BPA session. For two patients on whom repeated BPA sessions were performed, we additionally assessed cardiac output (CO), pulmonary vascular resistance (PVR), and mean pulmonary artery pressure (mPAP). Results: A total of 12 BPA procedures for nine patients were performed; repeated BPA sessions were performed for two patients. Our results show a reduction in BNP levels and improvement in WHO functional class, 6MWD, and SpO2 after the first BPA session. Improvement in 6MWD was statistically significant. Additionally, an improvement in pulmonary hemodynamic parameters was observed. Conclusions: Our data show that BPA is an effective interventional treatment modality, improving both the pulmonary hemodynamics and functional status. Moreover, BPA is safe and excellently tolerated.
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Affiliation(s)
- Anna Krigere
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Verners Roberts Kalejs
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Ricards Kaulins
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Ainars Rudzitis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Liga Bondare
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Matiss Sablinskis
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
| | - Aivars Lejnieks
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
- Department of Internal Diseases, Riga East Clinical University Hospital, 1038 Riga, Latvia
| | - Dana Kigitovica
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, ERN-LUNG Member, 05-400 Otwock, Poland
| | - Andris Skride
- Department of Rare Diseases, Pauls Stradins Clinical University Hospital, 1002 Riga, Latvia; (A.K.); (V.R.K.); (A.R.)
- Department of Internal Diseases, Riga Stradins University, 1007 Riga, Latvia; (R.K.); (A.L.)
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17
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Burggraaf-van Delft JLI, van Rein N, Bemelmans RHH, van den Berg JWK, Bruggeman CY, Cloos-van Balen M, Coppens M, Eefting M, Ende-Verhaar Y, van Es N, van Guldener C, de Jong WK, Kleijwegt F, Koster T, Kroon C, Kuipers S, Leentjens J, Luijten D, Mairuhu ATA, Meijer K, van de Ree MA, Roos R, Schrover I, Swart-Heikens J, van der Velden AWG, van den Akker-van Marle EM, le Cessie S, Geersing GJ, Middeldorp S, Huisman MV, Klok FA, Cannegieter SC. Tailored anticoagulant treatment after a first venous thromboembolism: protocol of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study - cohort-based randomised controlled trial. BMJ Open 2024; 14:e078676. [PMID: 38521524 PMCID: PMC10961563 DOI: 10.1136/bmjopen-2023-078676] [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: 08/08/2023] [Accepted: 02/06/2024] [Indexed: 03/25/2024] Open
Abstract
INTRODUCTION Patients with a first venous thromboembolism (VTE) are at risk of recurrence. Recurrent VTE (rVTE) can be prevented by extended anticoagulant therapy, but this comes at the cost of an increased risk of bleeding. It is still uncertain whether patients with an intermediate recurrence risk or with a high recurrence and high bleeding risk will benefit from extended anticoagulant treatment, and whether a strategy where anticoagulant duration is tailored on the predicted risks of rVTE and bleeding can improve outcomes. The aim of the Leiden Thrombosis Recurrence Risk Prevention (L-TRRiP) study is to evaluate the outcomes of tailored duration of long-term anticoagulant treatment based on individualised assessment of rVTE and major bleeding risks. METHODS AND ANALYSIS The L-TRRiP study is a multicentre, open-label, cohort-based, randomised controlled trial, including patients with a first VTE. We classify the risk of rVTE and major bleeding using the L-TRRiP and VTE-BLEED scores, respectively. After 3 months of anticoagulant therapy, patients with a low rVTE risk will discontinue anticoagulant treatment, patients with a high rVTE and low bleeding risk will continue anticoagulant treatment, whereas all other patients will be randomised to continue or discontinue anticoagulant treatment. All patients will be followed up for at least 2 years. Inclusion will continue until the randomised group consists of 608 patients; we estimate to include 1600 patients in total. The primary outcome is the combined incidence of rVTE and major bleeding in the randomised group after 2 years of follow-up. Secondary outcomes include the incidence of rVTE and major bleeding, functional outcomes, quality of life and cost-effectiveness in all patients. ETHICS AND DISSEMINATION The protocol was approved by the Medical Research Ethics Committee Leiden-Den Haag-Delft. Results are expected in 2028 and will be disseminated through peer-reviewed journals and during (inter)national conferences. TRIAL REGISTRATION NUMBER NCT06087952.
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Affiliation(s)
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Remy H H Bemelmans
- Department of Internal Medicine, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | | | - Coty Y Bruggeman
- Department of Internal Medicine, Martini Ziekenhuis, Groningen, Groningen, The Netherlands
| | - Marissa Cloos-van Balen
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Matthijs Eefting
- Department of Internal Medicine, Ikazia Ziekenhuis, Rotterdam, Zuid-Holland, The Netherlands
| | - Yvonne Ende-Verhaar
- Department of Internal Medicine, Medisch Centrum Haaglanden, Den Haag, Zuid-Holland, The Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Pulmonary Hypertension & Thrombosis, Amsterdam Cardiovascular Sciences, Amsterdam, Noord-Holland, The Netherlands
| | - Coen van Guldener
- Department of Internal Medicine, Amphia Ziekenhuis, Breda, North Brabant, The Netherlands
| | - Wouter K de Jong
- Department of Pulmonology, Ziekenhuis Gelderse Vallei, Ede, Gelderland, The Netherlands
| | - Fleur Kleijwegt
- Department of Internal Medicine, Rode Kruis Ziekenhuis, Beverwijk, Noord-Holland, The Netherlands
| | - Ted Koster
- Department of Internal Medicine, Groene Hart Ziekenhuis, Gouda, Zuid-Holland, The Netherlands
| | - Cees Kroon
- Department of Internal Medicine, Ziekenhuis Nij Smellinghe, Drachten, Friesland, The Netherlands
| | - Saskia Kuipers
- Department of Internal Medicine, ADRZ, Goes, Zeeland, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Albert T A Mairuhu
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Karina Meijer
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Marcel A van de Ree
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Rick Roos
- Department of Internal Medicine, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Ilse Schrover
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Swart-Heikens
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | | | | | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Clinical Epidemiology, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Geert-Jan Geersing
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud university medical center, Nijmegen, Gelderland, The Netherlands
| | - Menno V Huisman
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Davis S, Pandor A, Sampson FC, Hamilton J, Nelson-Piercy C, Hunt BJ, Daru J, Goodacre S, Carser R, Rooney G, Clowes M. Thromboprophylaxis during pregnancy and the puerperium: a systematic review and economic evaluation to estimate the value of future research. Health Technol Assess 2024; 28:1-176. [PMID: 38476084 PMCID: PMC11017156 DOI: 10.3310/dfwt3873] [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: 03/14/2024] Open
Abstract
Background Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research. Objectives To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians. Methods A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies. Results The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty. Limitations The performance of the risk assessment model for obese postpartum women has not been externally validated. Conclusions Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism. Study registration This study is registered as PROSPERO CRD42020221094. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in Health Technology Assessment; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Fiona C Sampson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Beverley J Hunt
- Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Jahnavi Daru
- Institute of Population Health Sciences, Queen Mary University of London, London, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rosie Carser
- Patient and Public Involvement, Thrombosis UK, Llanwrda, UK
| | - Gill Rooney
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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19
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Howard LS, Price LC. Systematic pulmonary embolism follow-up: why we should all do it! Eur Respir J 2024; 63:2400253. [PMID: 38485183 DOI: 10.1183/13993003.00253-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 02/05/2024] [Indexed: 03/19/2024]
Affiliation(s)
- Luke S Howard
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Laura C Price
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, Guys and Thomas's NHS Foundation Trust, London, UK
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20
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Provencher S, Mai V, Bonnet S. Managing Pulmonary Arterial Hypertension With Cardiopulmonary Comorbidities. Chest 2024; 165:682-691. [PMID: 38461018 DOI: 10.1016/j.chest.2023.08.023] [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: 04/28/2023] [Revised: 08/10/2023] [Accepted: 08/25/2023] [Indexed: 03/11/2024] Open
Abstract
Pulmonary arterial hypertension (PAH) and pulmonary hypertension associated with left-sided heart and lung diseases are most commonly easily discriminated and treated accordingly. With the changing epidemiology of PAH, however, a growing proportion of patients at the time of diagnosis present with comorbidities of varying severity. In addition to classical PAH, two distinct phenotypes have emerged: a heart failure with preserved ejection fraction-like phenotype and a lung phenotype. Importantly, the evidence supporting the currently proposed treatment algorithm for PAH has been generated mainly from PAH trials in which patients with cardiopulmonary comorbidities have been underrepresented or excluded. As a consequence, the best therapeutic approach for patients with common PAH with cardiopulmonary comorbidities remains largely unknown and requires further investigation. The present article reviews the relevant literature on the topic and describes the authors' views on the current therapeutic approach for these patients.
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Affiliation(s)
- Steeve Provencher
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada.
| | - Vicky Mai
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Sebastien Bonnet
- Institut Universitaire de Cardiologie et de Pneumologie de Québec Research Center, Université Laval, Quebec City, QC, Canada; Pulmonary Hypertension Research Group, Université Laval, Quebec City, QC, Canada; Department of Medicine, Université Laval, Quebec City, QC, Canada
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21
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Zheng Z, Pandit K, Chang AR, Shin JI, Charytan DM, Grams ME, Surapaneni A. Association of eGFR and Albuminuria with Venous Thromboembolism. Clin J Am Soc Nephrol 2024; 19:301-308. [PMID: 37971889 PMCID: PMC10937012 DOI: 10.2215/cjn.0000000000000352] [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: 05/26/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND CKD has been implicated as a risk factor of venous thromboembolism, but the evidence is limited to relatively healthy populations. The objective of this study was to discern whether parameters of kidney function and damage are associated with the occurrence of venous thromboembolism after hospitalization. METHODS We conducted a retrospective study including 23,899 and 11,552 adult individuals hospitalized within Geisinger Health System and New York University (NYU) Langone Health from 2004 to 2019 and 2012 to 2022, respectively. A Poisson model was used to evaluate adjusted incidence rates of venous thromboembolism according to eGFR and albuminuria categories in each cohort. Cox proportional hazards models were used to analyze associations of eGFR and urinary albumin-to-creatinine ratio (UACR) with venous thromboembolism, and hazard ratios (HRs) were meta-analyzed across cohorts. RESULTS Both lower eGFR and higher UACR were associated with higher risks of venous thromboembolism. In the Geisinger cohort, the incidence of venous thromboembolism after hospital discharge ranged from 10.7 (95% confidence interval [CI], 9.2 to 12.6) events per 1000 person-years in individuals in G1A1 (eGFR >90 ml/min per 1.73 m 2 and UACR <30 mg/g) to 27.7 (95% CI, 20.6 to 37.2) events per 1000 person-years in individuals with G4-5A3 (eGFR <30 ml/min per 1.73 m 2 and UACR >300 mg/g). A similar pattern was observed in the NYU cohort. Meta-analyses of the two cohorts showed that every 10 ml/min per 1.73 m 2 reduction in eGFR below 60 ml/min per 1.73 m 2 was associated with a 6% higher risk of venous thromboembolism (HR 1.06 [95% CI, 1.02 to 1.11], P = 0.01), and each two-fold higher UACR was associated with a 5% higher risk of venous thromboembolism (HR 1.05 [95% CI, 1.03 to 1.07], P < 0.001). CONCLUSIONS Both eGFR and UACR were independently associated with higher risk of venous thromboembolism after hospitalization. The incidence rate was higher with greater severity of CKD. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2023_12_14_CJN0000000000000352.mp3.
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Affiliation(s)
- Zhong Zheng
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Krutika Pandit
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Alex R. Chang
- Kidney Health Research Institute, Geisinger, Danville, Pennsylvania
| | - Jung-Im Shin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - David M. Charytan
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Morgan E. Grams
- Nephrology Division, Department of Medicine, New York University Grossman School of Medicine, New York, New York
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Aditya Surapaneni
- Division of Precision Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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22
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Durrington C, Hurdman JA, Elliot CA, Maclean R, Van Veen J, Saccullo G, De-Foneska D, Swift AJ, Smitha R, Hill C, Thomas S, Dwivedi K, Alabed S, Wild JM, Charalampopoulos A, Hameed A, Rothman AMK, Watson L, Hamilton N, Thompson AAR, Condliffe R, Kiely DG. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J 2024; 63:2300846. [PMID: 38302154 PMCID: PMC7615743 DOI: 10.1183/13993003.00846-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. METHODS Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. RESULTS Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. CONCLUSIONS In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.
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Affiliation(s)
- Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Judith A Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rhona Maclean
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joost Van Veen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Giorgia Saccullo
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Duneesha De-Foneska
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Rajaram Smitha
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Krit Dwivedi
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Samer Alabed
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - James M Wild
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Alexander M K Rothman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
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23
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Davis S, Goodacre S, Horner D, Pandor A, Holland M, de Wit K, Hunt BJ, Griffin XL. Effectiveness and cost effectiveness of pharmacological thromboprophylaxis for medical inpatients: decision analysis modelling study. BMJ MEDICINE 2024; 3:e000408. [PMID: 38389721 PMCID: PMC10882286 DOI: 10.1136/bmjmed-2022-000408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/03/2024] [Indexed: 02/24/2024]
Abstract
Objective To determine the balance of costs, risks, and benefits for different thromboprophylaxis strategies for medical patients during hospital admission. Design Decision analysis modelling study. Setting NHS hospitals in England. Population Eligible adult medical inpatients, excluding patients in critical care and pregnant women. Interventions Pharmacological thromboprophylaxis (low molecular weight heparin) for all medical inpatients, thromboprophylaxis for none, and thromboprophylaxis given to higher risk inpatients according to risk assessment models (Padua, Caprini, IMPROVE, Intermountain, Kucher, Geneva, and Rothberg) previously validated in medical cohorts. Main outcome measures Lifetime costs and quality adjusted life years (QALYs). Costs were assessed from the perspective of the NHS and Personal Social Services in England. Other outcomes assessed were incidence and treatment of venous thromboembolism, major bleeds including intracranial haemorrhage, chronic thromboembolic complications, and overall survival. Results Offering thromboprophylaxis to all medical inpatients had a high probability (>99%) of being the most cost effective strategy (at a threshold of £20 000 (€23 440; $25 270) per QALY) in the probabilistic sensitivity analysis, when applying performance data from the Padua risk assessment model, which was typical of that observed across several risk assessment models in a medical inpatient cohort. Thromboprophylaxis for all medical inpatients was estimated to result in 0.0552 additional QALYs (95% credible interval 0.0209 to 0.1111) while generating cost savings of £28.44 (-£47 to £105) compared with thromboprophylaxis for none. No other risk assessment model was more cost effective than thromboprophylaxis for all medical inpatients when assessed in deterministic analysis. Risk based thromboprophylaxis was found to have a high (76.6%) probability of being the most cost effective strategy only when assuming a risk assessment model with very high sensitivity is available (sensitivity 99.9% and specificity 23.7% v base case sensitivity 49.3% and specificity 73.0%). Conclusions Offering pharmacological thromboprophylaxis to all eligible medical inpatients appears to be the most cost effective strategy. To be cost effective, any risk assessment model would need to have a very high sensitivity resulting in widespread thromboprophylaxis in all patients except those at the very lowest risk, who could potentially avoid prophylactic anticoagulation during their hospital stay.
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Affiliation(s)
- Sarah Davis
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Daniel Horner
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
- Department of Emergency and Intensive Care Medicine, Northern Care Alliance Foundation Trust, Salford, UK
- Division of Immunology, Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | - Abdullah Pandor
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Mark Holland
- School of Clinical and Biomedical Sciences, Faculty of Health and Wellbeing, University of Bolton, Bolton, UK
| | - Kerstin de Wit
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Beverley J Hunt
- Department of Thrombosis & Haemostasis, Kings Healthcare Partners, London, UK
| | - Xavier Luke Griffin
- Barts Bone and Joint Health, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [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: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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25
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Nguyen R, Murra A, Capdeville M. Chronic Thromboembolic Pulmonary Hypertension Due to a Rare Anterior Mediastinal Venous Malformation. J Cardiothorac Vasc Anesth 2024; 38:552-557. [PMID: 36528502 DOI: 10.1053/j.jvca.2022.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 11/16/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Rachel Nguyen
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Ali Murra
- College of Medicine, Northeast Ohio Medical University, Rootstown, OH
| | - Michelle Capdeville
- Department of Cardiothoracic Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH.
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26
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Awad MA, Cires-Drouet R, Ramani G, Leibowitz JL, Shah A, Lau CL, Griffith BP. Pulmonary thromboendarterectomy in hospitalized versus elective patients with chronic thromboembolic pulmonary hypertension. J Thorac Cardiovasc Surg 2024; 167:526-534. [PMID: 37611847 DOI: 10.1016/j.jtcvs.2023.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 08/09/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVE We sought to characterize outcomes in patients undergoing pulmonary thromboendarterectomy electively versus after acute presentation. METHODS This is a retrospective analysis of patients who underwent pulmonary thromboendarterectomy from October 2015 to April 2022. Patients were divided into 2 groups depending on elective surgery or surgery during the same hospitalization as their presentation. RESULTS In total, 69 patients were included: 45 in the hospitalized group and 24 in the elective group. Patients in the hospitalized group were less likely to have chronic lung disease, history of pulmonary embolism and hypertension, be on anticoagulation and medication for pulmonary hypertension, and present with >1 month of respiratory symptoms. They were more likely to have worse preoperative right ventricular function. Among other demographics, risk factors for venous thromboembolism were similar between both groups. Thirteen patients in the hospitalized group required preoperative extracorporeal membrane oxygenation. There was no difference in disease classification and operative, cardiopulmonary bypass, and hypothermic circulatory arrest durations between both groups. Postoperative complications were similar between both groups, except for greater frequency of deep vein thrombosis in the hospitalized group (26.7% vs 4.2%, P = .03). In-hospital and intensive care unit length of stay were similar between both groups. Overall, in-hospital mortality was 4.3% and was similar between both groups; P = .28. CONCLUSIONS Our series shows that pulmonary thromboendarterectomy can be safely performed in patients presenting acutely, with comparable postoperative complications and in-hospital mortality to an elective setting. Such patients present with worse right ventricular function, sometimes requiring temporary mechanical support.
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Affiliation(s)
- Morcos A Awad
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Rafael Cires-Drouet
- Department of Medicine, University of Maryland Medical Center, Baltimore, Md
| | - Gautam Ramani
- Department of Medicine, University of Maryland Medical Center, Baltimore, Md
| | - Joshua L Leibowitz
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Aakash Shah
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Christine L Lau
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Bartley P Griffith
- Department of Surgery, University of Maryland Medical Center, Baltimore, Md.
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Yamasaki Y, Kamitani T, Sagiyama K, Hino T, Kisanuki M, Tabata K, Isoda T, Kitamura Y, Abe K, Hosokawa K, Toyomura D, Moriyama S, Kawakubo M, Yabuuchi H, Ishigami K. Dynamic chest radiography for pulmonary vascular diseases: clinical applications and correlation with other imaging modalities. Jpn J Radiol 2024; 42:126-144. [PMID: 37626168 PMCID: PMC10811043 DOI: 10.1007/s11604-023-01483-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
Dynamic chest radiography (DCR) is a novel functional radiographic imaging technique that can be used to visualize pulmonary perfusion without using contrast media. Although it has many advantages and clinical utility, most radiologists are unfamiliar with this technique because of its novelty. This review aims to (1) explain the basic principles of lung perfusion assessment using DCR, (2) discuss the advantages of DCR over other imaging modalities, and (3) review multiple specific clinical applications of DCR for pulmonary vascular diseases and compare them with other imaging modalities.
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Affiliation(s)
- Yuzo Yamasaki
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan.
| | - Takeshi Kamitani
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Koji Sagiyama
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takuya Hino
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Megumi Kisanuki
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
- Department of Hematology, Oncology and Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kosuke Tabata
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Takuro Isoda
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Yoshiyuki Kitamura
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
| | - Kohtaro Abe
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazuya Hosokawa
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Daisuke Toyomura
- Department of Pediatrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shohei Moriyama
- Department of Hematology, Oncology and Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masateru Kawakubo
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hidetake Yabuuchi
- Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-Ku, Fukuoka, 812-8582, Japan
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28
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Colombo C, Capsoni N, Russo F, Iannaccone M, Adamo M, Viola G, Bossi IE, Villanova L, Tognola C, Curci C, Morelli F, Guerrieri R, Occhi L, Chizzola G, Rampoldi A, Musca F, De Nittis G, Galli M, Boccuzzi G, Savio D, Bernasconi D, D’Angelo L, Garascia A, Chieffo A, Montorfano M, Oliva F, Sacco A. Ultrasound-Assisted, Catheter-Directed Thrombolysis for Acute Intermediate/High-Risk Pulmonary Embolism: Design of the Multicenter USAT IH-PE Registry and Preliminary Results. J Clin Med 2024; 13:619. [PMID: 38276125 PMCID: PMC10816433 DOI: 10.3390/jcm13020619] [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: 12/19/2023] [Revised: 01/18/2024] [Accepted: 01/20/2024] [Indexed: 01/27/2024] Open
Abstract
Catheter-based revascularization procedures were developed as an alternative to systemic thrombolysis for patients with intermediate-high- and high-risk pulmonary embolisms. USAT IH-PE is a retrospective and prospective multicenter registry of such patients treated with ultrasound-facilitated, catheter-directed thrombolysis, whose preliminary results are presented in this study. The primary endpoint was the incidence of pulmonary hypertension (PH) at follow-up. Secondary endpoints were short- and mid-term changes in the echocardiographic parameters of right ventricle (RV) function, in-hospital and all-cause mortality, and procedure-related bleeding events. Between March 2018 and July 2023, 102 patients were included. The majority were at intermediate-high-risk PE (86%), were mostly female (57%), and had a mean age of 63.7 ± 14.5 years, and 28.4% had active cancer. Echocardiographic follow-up was available for 70 patients, and in only one, the diagnosis of PH was confirmed by right heart catheterization, resulting in an incidence of 1.43% (CI 95%, 0.036-7.7). RV echocardiographic parameters improved both at 24 h and at follow-up. In-hospital mortality was 3.9% (CI 95%, 1.08-9.74), while all-cause mortality was 11% (CI 95%, 5.4-19.2). Only 12% had bleeding complications, of whom 4.9% were BARC ≥ 3. Preliminary results from the USAT IH-PE registry showed a low incidence of PH, improvement in RV function, and a safe profile.
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Affiliation(s)
- Claudia Colombo
- 1st Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.C.); (G.V.); (L.V.); (F.O.)
| | - Nicolò Capsoni
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (N.C.); (I.E.B.); (C.C.); (R.G.)
| | - Filippo Russo
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (F.R.); (A.C.); (M.M.)
| | - Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, 10154 Turin, Italy; (M.I.); (G.B.)
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, 25123 Brescia, Italy;
| | - Giovanna Viola
- 1st Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.C.); (G.V.); (L.V.); (F.O.)
| | - Ilaria Emanuela Bossi
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (N.C.); (I.E.B.); (C.C.); (R.G.)
| | - Luca Villanova
- 1st Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.C.); (G.V.); (L.V.); (F.O.)
| | - Chiara Tognola
- 4th Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.T.); (L.O.); (F.M.)
| | - Camilla Curci
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (N.C.); (I.E.B.); (C.C.); (R.G.)
| | - Francesco Morelli
- Department of Interventional Radiology, Niguarda Cà Granda Hospital, 20142 Milan, Italy; (F.M.); (A.R.)
| | - Rossella Guerrieri
- Department of Emergency Medicine, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (N.C.); (I.E.B.); (C.C.); (R.G.)
| | - Lucia Occhi
- 4th Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.T.); (L.O.); (F.M.)
| | - Giuliano Chizzola
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia, 25121 Brescia, Italy;
| | - Antonio Rampoldi
- Department of Interventional Radiology, Niguarda Cà Granda Hospital, 20142 Milan, Italy; (F.M.); (A.R.)
| | - Francesco Musca
- 4th Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.T.); (L.O.); (F.M.)
| | - Giuseppe De Nittis
- Cardiovascular Interventional Unit, Cardiology Department, S. Anna Hospital, 10126 Como, Italy; (G.D.N.); (M.G.)
| | - Mario Galli
- Cardiovascular Interventional Unit, Cardiology Department, S. Anna Hospital, 10126 Como, Italy; (G.D.N.); (M.G.)
| | - Giacomo Boccuzzi
- Division of Cardiology, San Giovanni Bosco Hospital, 10154 Turin, Italy; (M.I.); (G.B.)
| | - Daniele Savio
- Department of Interventional Radiology, San Giovanni Bosco Hospital, 10154 Turin, Italy;
| | - Davide Bernasconi
- Bicocca Bioinformatics Biostatistics and Bioimaging (B4) Center, School of Medicine and Surgery, University of Milano-Bicocca, 20126 Bicocca, Italy;
- Department of Clinical Research and Innovation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Luciana D’Angelo
- 2nd Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (L.D.); (A.G.)
| | - Andrea Garascia
- 2nd Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (L.D.); (A.G.)
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (F.R.); (A.C.); (M.M.)
| | - Matteo Montorfano
- Interventional Cardiology Unit, IRCCS San Raffaele Hospital, 20132 Milan, Italy; (F.R.); (A.C.); (M.M.)
| | - Fabrizio Oliva
- 1st Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.C.); (G.V.); (L.V.); (F.O.)
| | - Alice Sacco
- 1st Division of Cardiology, De Gasperis Cardio Center, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy; (C.C.); (G.V.); (L.V.); (F.O.)
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Marin-Romero S, Ballaz-Quincoces A, Gómez-Cuervo C, Marchena-Yglesias PJ, Lopez-Miguel P, Francisco-Albesa I, Pedrajas-Navas JM, Lumbierres M, Aibar-Arregui MA, Bosco Lopez-Saez J, Perez-Pinar M, Baeza-Martinez C, Riera-Mestre A, Peris-Sifre M, Porras-Ledantes JA, Criado-Garcia J, Elias-Hernandez T, Otero R, Barca-Hernando M, Muriel A, Klok FA, Jara-Palomares L. Symptom-related screening programme for early detection of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism: the SYSPPE study. Thorax 2024; 79:144-152. [PMID: 38050187 PMCID: PMC10850838 DOI: 10.1136/thorax-2023-220580] [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: 06/13/2023] [Accepted: 11/16/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is the most severe long-term complication of acute pulmonary embolism (PE). We aimed to evaluate the impact of a symptom screening programme to detect CTEPH in PE survivors. METHODS This was a multicentre cohort study of patients diagnosed with acute symptomatic PE between January 2017 and December 2018 in 16 centres in Spain. Patients were contacted by phone 2 years after the index PE diagnosis. Those with dyspnoea corresponding to a New York Heart Association (NYHA)/WHO scale≥II, visited the outpatient clinic for echocardiography and further diagnostic tests including right heart catheterisation (RHC). The primary outcome was the new diagnosis of CTEPH confirmed by RHC. RESULTS Out of 1077 patients with acute PE, 646 were included in the symptom screening. At 2 years, 21.8% (n=141) reported dyspnoea NYHA/WHO scale≥II. Before symptom screening protocol, five patients were diagnosed with CTEPH following routine care. In patients with NYHA/WHO scale≥II, after symptom screening protocol, the echocardiographic probability of pulmonary hypertension (PH) was low, intermediate and high in 76.6% (n=95), 21.8% (n=27) and 1.6% (n=2), respectively. After performing additional diagnostic test in the latter 2 groups, 12 additional CTEPH cases were confirmed. CONCLUSIONS The implementation of this simple strategy based on symptom evaluation by phone diagnosed more than doubled the number of CTEPH cases. Dedicated follow-up algorithms for PE survivors help diagnosing CTEPH earlier. TRIAL REGISTRATION NUMBER NCT03953560.
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Affiliation(s)
- Samira Marin-Romero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | | | | | | | | | | | | | - Marina Lumbierres
- Respiratory Department, Arnau de Vilanova University Hospital, Lleida, Spain
| | | | | | | | | | - Antoni Riera-Mestre
- Internal Medicine, Bellvitge University Hospital, L'Hospitalet de Llobregat, Spain
- Instituto de Investigación Biomédica de Bellvitge, Barcelona, Spain
- Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universitat de Barcelona, Barcelona, Spain
| | - Marisa Peris-Sifre
- Internal Medicine Unit, Hospital Provincial Castellon, Castellon de la Plana, Spain
- CEU Cardenal Herrera University, Moncada, Spain
| | | | | | - Teresa Elias-Hernandez
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Remedios Otero
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Maria Barca-Hernando
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
| | - Alfonso Muriel
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
- Biostatistics Department, Hospital Universitario Ramon y Cajal, Madrid, Spain
- University of Alcala, Alcala de Henares, Spain
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Luis Jara-Palomares
- Respiratory Unit, Medical-Surgical Unit of Respiratory Diseases, Virgen del Rocio University Hospital, Sevilla, Spain
- Center for Biomedical Research in Respiratory Diseases Network (CIBERES), Carlos III Health Institute, Madrid, Spain
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30
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Sun LL, Liu Z, Ran F, Huang D, Zhang M, Li XQ, Li WD. Non-coding RNAs regulating endothelial progenitor cells for venous thrombosis: promising therapy and innovation. Stem Cell Res Ther 2024; 15:7. [PMID: 38169418 PMCID: PMC10762949 DOI: 10.1186/s13287-023-03621-z] [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: 09/19/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024] Open
Abstract
Venous thromboembolism, which includes deep venous thrombosis (DVT) and pulmonary embolism, is the third most common vascular disease in the world and seriously threatens the lives of patients. Currently, the effect of conventional treatments on DVT is limited. Endothelial progenitor cells (EPCs) play an important role in the resolution and recanalization of DVT, but an unfavorable microenvironment reduces EPC function. Non-coding RNAs, especially long non-coding RNAs and microRNAs, play a crucial role in improving the biological function of EPCs. Non-coding RNAs have become clinical biomarkers of diseases and are expected to serve as new targets for disease intervention. A theoretical and experimental basis for the development of new methods for preventing and treating DVT in the clinic will be provided by studies on the role and molecular mechanism of non-coding RNAs regulating EPC function in the occurrence and development of DVT. To summarize, the characteristics of venous thrombosis, the regulatory role of EPCs in venous thrombosis, and the effect of non-coding RNAs regulating EPCs on venous thrombosis are reviewed. This summary serves as a useful reference and theoretical basis for research into the diagnosis, prevention, treatment, and prognosis of venous thrombosis.
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Affiliation(s)
- Li-Li Sun
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Zhao Liu
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Feng Ran
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Dian Huang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Ming Zhang
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xiao-Qiang Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
| | - Wen-Dong Li
- Department of Vascular Surgery, Nanjing Drum Tower Hospital, The Affiliate Hospital of Nanjing University Medical School, #321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
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31
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Kopeć G, Forfia P, Abe K, Beaudet A, Gressin V, Jevnikar M, Meijer C, Tan YZ, Moiseeva O, Sheares K, Skoro‐Sajer N, Terra‐Filho M, Whitford H, Zhai Z, Heresi GA. Recognition, diagnosis, and operability assessment of chronic thromboembolic pulmonary hypertension (CTEPH): A global cross-sectional scientific survey (CLARITY). Pulm Circ 2024; 14:e12330. [PMID: 38384932 PMCID: PMC10880430 DOI: 10.1002/pul2.12330] [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: 03/03/2023] [Revised: 12/07/2023] [Accepted: 12/19/2023] [Indexed: 02/23/2024] Open
Abstract
Early recognition and diagnosis of chronic thromboembolic pulmonary hypertension (CTEPH) is crucial for improving prognosis and reducing the disease burden. Established clinical practice guidelines describe interventions for the diagnosis and evaluation of CTEPH, yet limited insight remains into clinical practice variation and barriers to care. The CTEPH global cross-sectional scientific survey (CLARITY) was developed to gather insights into the current diagnosis, treatment, and management of CTEPH and to identify unmet medical needs. This paper focuses on the recognition and diagnosis of CTEPH and the referral and evaluation of these patients. The survey was offered to hospital-based medical specialists through Scientific Societies and other medical organizations, from September 2021 to May 2022. Response data from 353 physicians showed that self-reported awareness of CTEPH increased over the past 10 years among 96% of respondents. Clinical practices in acute pulmonary embolism (PE) follow-up and CTEPH diagnosis differed among respondents. While 50% of respondents working in a nonexpert center reported to refer patients to an expert pulmonary hypertension/CTEPH center when CTEPH is suspected, 51% of these physicians did not report referral of patients with a confirmed diagnosis for further evaluation. Up to 50% of respondents involved in the evaluation of referred patients have concluded a different operability status than that indicated by the referring center. This study indicates that early diagnosis and timely treatment of CTEPH is challenged by suboptimal acute PE follow-up and patient referral practices. Nonadherence to guideline recommendations may be impacted by various barriers to care, which were shown to vary by geographical region.
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Affiliation(s)
- Grzegorz Kopeć
- Pulmonary Circulation Centre, Department of Cardiac and Vascular Diseases, Faculty of MedicineJagiellonian University Medical CollegeKrakowPoland
- St. John Paul II HospitalKrakowPoland
| | - Paul Forfia
- Temple University HospitalPhiladelphiaPennsylvaniaUSA
| | | | - Amélie Beaudet
- Actelion Pharmaceuticals Ltd., A Janssen Pharmaceutical Company of Johnson & JohnsonGlobal Market AccessAllschwilSwitzerland
| | - Virginie Gressin
- Actelion Pharmaceuticals Ltd.A Janssen Pharmaceutical Company of Johnson & Johnson, Global Medical AffairsAllschwilSwitzerland
| | | | | | | | - Olga Moiseeva
- Almazov National Medical Research CenterSt. PetersburgRussia
| | | | | | - Mario Terra‐Filho
- Pulmonary Division–Heart Institute (Incor)University of Sao PauloSao PauloBrazil
| | | | - Zhenguo Zhai
- State Key Laboratory of Respiratory Health and Multimorbidity, Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China‐Japan Friendship Hospital, National Center for Respiratory Medicine, National Clinical Research Center for Respiratory Diseases Institute of Respiratory MedicineChinese Academy of Medical SciencesBeijingChina
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32
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Tavares V, Neto BV, Marques IS, Assis J, Pereira D, Medeiros R. Cancer-associated thrombosis: What about microRNAs targeting the tissue factor coagulation pathway? Biochim Biophys Acta Rev Cancer 2024; 1879:189053. [PMID: 38092078 DOI: 10.1016/j.bbcan.2023.189053] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 12/03/2023] [Accepted: 12/08/2023] [Indexed: 12/18/2023]
Abstract
Cancer patients are often diagnosed with venous thromboembolism (VTE), a cardiovascular disease that substantially decreases their quality of life and survival rate. Haemostasis in these patients is deregulated, which is reflected in the common presentation of a blood hypercoagulation state. Despite the inconsistent results, existing evidence suggests that the expression of microRNAs (miRNAs) is deregulated in the context of venous thrombogenesis in the general population. However, few miRNAs are known to be linked to cancer-associated VTE due to the lack of studies with oncological patients. Parallelly, coagulation factor III, also known as tissue factor (TF), tissue factor pathway inhibitor 1 (TFPI1) and tissue factor pathway inhibitor 2 (TFPI2) have been proposed to have a central role in cancer-associated VTE and tumour progression. Yet, contrary to what was expected, the role of miRNAs targeting the TF coagulation pathway (or extrinsic coagulation pathway) is poorly explored in cancer-induced thrombogenesis. In this review, in addition to miRNAs implicated in VTE, TF and TFPI1/2-targeting miRNAs were revised. Future studies should clarify the implications of these non-coding RNAs in tumour coagulome.
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Affiliation(s)
- Valéria Tavares
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Medicine of University of Porto (FMUP), 4200-072 Porto, Portugal; Abel Salazar Institute for the Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal
| | - Beatriz Vieira Neto
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Research Department, Portuguese League Against Cancer (NRNorte), 4200-172 Porto, Portugal
| | - Inês Soares Marques
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Sciences of University of Porto (FCUP), 4169-007 Porto, Portugal
| | - Joana Assis
- Clinical Research Unit, Research Center of IPO Porto (CI-IPOP) / RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Center (Porto.CCC), 4200-072 Porto, Portugal
| | - Deolinda Pereira
- Oncology Department, Portuguese Institute of Oncology of Porto (IPO Porto), 4200-072 Porto, Portugal
| | - Rui Medeiros
- Molecular Oncology and Viral Pathology Group, Research Center of IPO Porto (CI-IPOP)/ Pathology and Laboratory Medicine Dep., Clinical Pathology SV/ RISE@CI-IPOP (Health Research Network), Portuguese Oncology Institute of Porto (IPO Porto) / Porto Comprehensive Cancer Centre (Porto.CCC), 4200-072 Porto, Portugal; Faculty of Medicine of University of Porto (FMUP), 4200-072 Porto, Portugal; Abel Salazar Institute for the Biomedical Sciences (ICBAS), University of Porto, 4050-313 Porto, Portugal; Research Department, Portuguese League Against Cancer (NRNorte), 4200-172 Porto, Portugal; Faculty of Health Sciences, Fernando Pessoa University, 4200-150 Porto, Portugal.
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Verbelen T, Godinas L, Dorfmüller P, Gopalan D, Condliffe R, Delcroix M. Clinical-radiological-pathological correlation in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2023; 32:230149. [PMID: 38123236 PMCID: PMC10731457 DOI: 10.1183/16000617.0149-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 10/29/2023] [Indexed: 12/23/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and potentially life-threatening complication of acute pulmonary embolism. It is characterised by persistent fibro-thrombotic pulmonary vascular obstructions and elevated pulmonary artery pressure leading to right heart failure. The diagnosis is based on two steps, as follows: 1) suspicion based on symptoms, echocardiography and ventilation/perfusion scan and 2) confirmation with right heart catheterisation, computed tomography pulmonary angiography and, in most cases, digital subtraction angiography. The management of CTEPH requires a multimodal approach, involving medical therapy, interventional procedures and surgical intervention. This clinical-radiological-pathological correlation paper illustrates the diagnostic and therapeutic management of two patients. The first had chronic thromboembolic pulmonary disease without pulmonary hypertension at rest but with significant physical limitation and was successfully treated with pulmonary endarterectomy. The second patient had CTEPH associated with splenectomy and was considered unsuitable for surgery because of exclusive subsegmental lesions combined with severe pulmonary hypertension. The patient benefited from multimodal treatment involving medical therapy followed by multiple sessions of balloon pulmonary angioplasty. Both patients had normalised functional capacity and pulmonary haemodynamics 3-6 months after the interventional treatment. These two examples show that chronic thromboembolic pulmonary diseases are curable if diagnosed promptly and referred to CTEPH centres for specialist treatment.
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Affiliation(s)
- Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven - University of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Dorfmüller
- Institut für Pathologie, Universitätsklinikum Giessen/Marburg and Deutsches Zentrum für Lungenforschung (DZL), Giessen, Germany
| | - Deepa Gopalan
- Department of Radiology, Imperial College Hospital NHS Trust, London, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Leuven, Belgium
- Department of Chronic Diseases and Metabolism (CHROMETA), KU Leuven - University of Leuven, Leuven, Belgium
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Zeng X, Wu Z, Cen C, Wen S, Wang W, Zhou J, Wang T. Thrombosis is not the only determinant of chronic thromboembolic pulmonary hypertension. Int J Cardiol 2023; 392:131304. [PMID: 37652276 DOI: 10.1016/j.ijcard.2023.131304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 08/29/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Xiaohui Zeng
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhixiong Wu
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Chunxian Cen
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Shanshan Wen
- Guangzhou Medical University, Guangzhou, Guangdong 510623, China
| | - Weilin Wang
- Guangzhou Medical University, Guangzhou, Guangdong 510623, China
| | - Jingdong Zhou
- Guangzhou Medical University, Guangzhou, Guangdong 510623, China
| | - Tao Wang
- State Key Laboratory of Respiratory Diseases, Guangdong Key Laboratory of Vascular Diseases, National Clinical Research Center for Respiratory Diseases, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China.
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Pargana J, Calé R, Martinho M, Santos J, Lourenço C, Castro Pereira JA, Araújo P, Morgado J, Pereira E, Judas T, Alegria S, Ferreira F, Delerue F, Pereira H. Prevalence and predictors of chronic thromboembolic pulmonary hypertension following severe forms of acute pulmonary embolism. Rev Port Cardiol 2023; 42:947-958. [PMID: 37652118 DOI: 10.1016/j.repc.2023.06.007] [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: 04/07/2023] [Revised: 05/26/2023] [Accepted: 06/05/2023] [Indexed: 09/02/2023] Open
Abstract
INTRODUCTION AND OBJECTIVES The true prevalence of chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary embolism (PE) in the Portuguese population remains unknown. We aimed to assess the prevalence and predictors of CTEPH two years after a symptomatic high- (HR) or intermediate-high risk (IHR) PE. METHODS We conducted a retrospective cohort study of patients admitted with PE between 2014 and 2019 to a Portuguese referral center for pulmonary hypertension. RESULTS In this single-center registry of 969 patients admitted with PE (annual incidence of 46/100000 population), 194 had HR (5.4%) and IHR (14.7%) PE. After excluding patients who died or had no follow-up in the first three months, 129 patients were included in the analysis. The overall prevalence of suspected CTEPH by clinical assessment, Doppler echocardiography and V/Q lung scan was 6.2% (eight patients). CTEPH was confirmed by right heart catheterization in four of these (3.1%). Increased pulmonary artery systolic pressure (PASP) at admission (OR 1.12; 95% CI 1.04-1.22; p=0.005) and the presence of varicose veins in the lower limbs (OR 7.47; 95% CI 1.53-36.41; p=0.013) were predictors of CTEPH. PASP >60 mmHg at admission identified patients with CTEPH at follow-up with sensitivity and specificity of 83.3% and 76.3%, respectively. All patients diagnosed with CTEPH had at least two radiological findings suggestive of CTEPH at the index event. CONCLUSIONS In our cohort, the prevalence of CTEPH in survivors of severe forms of acute PE was 6.2%. PASP above 60 mmHg and supporting radiological findings on the index computed tomography scan are highly suggestive of acute-on-chronic CTEPH.
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Affiliation(s)
- Joana Pargana
- Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Lisbon University, Portugal
| | - Rita Calé
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal.
| | - Mariana Martinho
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - João Santos
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Cândida Lourenço
- Department of Radiology, Hospital Garcia de Orta, Almada, Portugal
| | | | - Patrícia Araújo
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - João Morgado
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Ernesto Pereira
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal; Escola Superior de Saúde da Cruz Vermelha Portuguesa, Lisboa, Portugal
| | - Tiago Judas
- Department of Internal Medicine, Hospital Garcia de Orta, Almada, Portugal
| | - Sofia Alegria
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Filipa Ferreira
- Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
| | - Francisca Delerue
- Department of Internal Medicine, Hospital Garcia de Orta, Almada, Portugal
| | - Hélder Pereira
- Centro Cardiovascular da Universidade de Lisboa-CCUL (CCUL@RISE), CAML, Faculdade de Medicina, Lisbon University, Portugal; Department of Cardiology, Hospital Garcia de Orta, Almada, Portugal
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Ley L, Grimminger F, Richter M, Tello K, Ghofrani A, Bandorski D. The Early Detection of Pulmonary Hypertension. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:823-830. [PMID: 37882345 PMCID: PMC10853922 DOI: 10.3238/arztebl.m2023.0222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/26/2023] [Accepted: 09/26/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Up to 1% of the world population and 10% of all persons over age 65 suffer from pulmonary hypertension (PH). The latency from the first symptom to the diagnosis is more than one year on average, and more than three years in 20% of patients. 40% seek help from more than four different physicians until their condition is finally diagnosed. METHODS This review is based on publications retrieved by a selective literature search on pulmonary hypertension. RESULTS The most common causes of pulmonary hypertension are left heart diseases and lung diseases. Its cardinal symptom is exertional dyspnea that worsens as the disease progresses. Additional symptoms of right heart failure are seen in advanced stages. Pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) are rare, difficult to diagnose, and of particular clinical relevance because specific treatments are available. For this reason, strategies for the early detection of PAH and CTEPH have been developed. The clinical suspicion of PH arises in a patient who has nonspecific symptoms, electrocardiographic changes, and an abnormal (NT-pro-)BNP concentration. Once the suspicion of PH has been confirmed by echocardiography and, if necessary, differential-diagnostic evaluation with a cardiopulmonary stress test, and after the exclusion of a primary left heart disease or lung disease, the patient should be referred to a PH center for further diagnostic assessment, classification, and treatment. CONCLUSION If both the (NT-pro-)BNP and the ECG are normal, PH is unlikely. Knowledge of the characteristic clinical manifestations and test results of PH is needed so that patients can be properly selected for referral to specialists and experts in PH.
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Affiliation(s)
- Lukas Ley
- Justus-Liebig-University Gießen, Campus Kerckhoff, Bad Nauheim
| | | | | | | | | | - Dirk Bandorski
- Semmelweis University, Department of Medicine, 20099 Hamburg
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37
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Delcroix M, Belge C, Maleux G, Godinas L. Monographic Issue on Pulmonary Hypertension: Medical and Interventional Treatment for Chronic Thromboembolic Pulmonary Hypertension. Semin Respir Crit Care Med 2023; 44:840-850. [PMID: 37567250 DOI: 10.1055/s-0043-1770122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism. The reasons why clots do not resorb are incompletely understood, but the result is partial or complete fibrothrombotic obstruction of pulmonary arteries. A secondary microvasculopathy aggravates the pulmonary hypertension (PH) as a consequence of high flow and shear stress in the nonoccluded arteries. The treatment of CTEPH has long been purely surgical, but many patients were inoperable because of inaccessible lesions or severe comorbidities. Alternatives were developed, including medical therapy and more recently balloon pulmonary angioplasty (BPA). Depending on the generation of the obstructed vessels, the treatment will be surgical, up to the (sub)segmental level, or by BPA for more distal vessels. PH drugs are used to treat the microvasculopathy. The current paper describes the therapeutic management of inoperable patients: the medical approach with PH drugs used in mono- or combination therapy; the proper use of anticoagulants in CTEPH; the technique, indications, and results at short- and long-term of BPA; the multimodal approach for inoperable patients combining PH drugs and BPA; and the effects of rehabilitation. It shows the importance of a multidisciplinary approach to the disease.
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Affiliation(s)
- Marion Delcroix
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
| | - Catharina Belge
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
| | - Geert Maleux
- Clinical Department of Radiology, University Hospitals of Leuven, Leuven, Belgium
| | - Laurent Godinas
- Clinical Department of Respiratory Diseases, Department of Chronic Diseases and Metabolism (CHROMETA), Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), KU Leuven-University of Leuven, University Hospitals of Leuven, Leuven, Belgium
- European Reference Network on Rare Pulmonary Diseases (ERN-LUNG), Belgium
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38
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Nakazato K, Sugimoto K, Oikawa M, Takeishi Y. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension:its history and development, and regional medical cooperation in Fukushima. Fukushima J Med Sci 2023; 69:167-176. [PMID: 37766558 PMCID: PMC10694517 DOI: 10.5387/fms.2023-09] [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: 03/22/2023] [Accepted: 08/07/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is designated as an intractable disease by the Ministry of Health, Labour and Welfare of Japan, and has an extremely poor prognosis if untreated. Surgical pulmonary endarterectomy is the curative treatment for cases in which the organized thrombi are located in the central part of the pulmonary artery, but there had been no effective treatment for cases in which the thrombi are located in the peripheral part of the pulmonary artery. Recently, balloon pulmonary angioplasty (BPA), a transcatheter procedure to dilate stenotic or occluded lesions in the peripheral pulmonary artery, has been rapidly developed. Although BPA was once a globally abandoned procedure due to hemorrhagic complications, Japanese experts have improved the technique, and its safety and efficacy have been enhanced. As a result, BPA is now being reevaluated worldwide. This review describes the history and development of BPA in the treatment of CTEPH, as well as the status of this treatment in Fukushima Prefecture.
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Affiliation(s)
- Kazuhiko Nakazato
- Regional Medical Support Center, Fukushima Medical University
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University
- Futaba Emergency and General Medicine Support Center, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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Tello K, Richter MJ, Kremer N, Gall H, Egenlauf B, Sorichter S, Heberling M, Douschan P, Hager A, Yogeswaran A, Behr J, Xanthouli P, Held M. [Diagnostic Algorithm and Screening of Pulmonary Hypertension]. Pneumologie 2023; 77:871-889. [PMID: 37963477 DOI: 10.1055/a-2145-4678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
The new guidelines for the diagnosis and treatment of pulmonary hypertension include a new diagnostic algorithm and provide specific recommendations for the required diagnostic procedures, including screening methods. These recommendations are commented on by national experts under the auspices of the DACH. These comments provide additional decision support and background information, serving as a further guide for the complex diagnosis of pulmonary hypertension.
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Affiliation(s)
- Khodr Tello
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Manuel J Richter
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Nils Kremer
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Henning Gall
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Benjamin Egenlauf
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Stephan Sorichter
- Klinik für Pneumologie und Beatmungsmedizin, St.-Josefskrankenhaus, Freiburg im Breisgau, Deutschland
| | - Melanie Heberling
- Universitätsklinikum Dresden, Med. Klinik I, Pneumologie, Dresden, Deutschland
| | - Philipp Douschan
- Abteilung für Pulmonologie, Universitätsklinik für Innere Medizin, Graz, Österreich; Ludwig Boltzmann Institut für Lungengefäßforschung, Graz, Österreich
| | - Alfred Hager
- Department of Paediatric Cardiology and Congenital Heart Defects, Deutsches Herzzentrum München, München, Deutschland
| | - Athiththan Yogeswaran
- Medizinische Klinik II, Justus-Liebig-Universität Gießen, Universitäten Gießen und Marburg Lung Center (UGMLC), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Deutschland
| | - Jürgen Behr
- LMU Klinikum München, Medizinische Klinik und Poliklinik V, München, Deutschland. Comprehensive Pneumology Center (CPC-M), Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Panagiota Xanthouli
- Zentrum für pulmonale Hypertonie, Thoraxklinik Heidelberg gGmbH am Universitätsklinikum Heidelberg, Heidelberg, Deutschland, Mitglied des Deutschen Zentrums für Lungenforschung (DZL)
| | - Matthias Held
- Klinikum Würzburg Mitte, Medizinische Klinik Schwerpunkt Pneumologie & Beatmungsmedizin, Würzburg, Deutschland
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Adameit MSD, Wiedenroth CB, Omlor A, Schäfers HJ, Guth S, Wilkens H. [Chronic thromboembolic pulmonary hypertension]. Dtsch Med Wochenschr 2023; 148:1514-1523. [PMID: 37949080 DOI: 10.1055/a-2012-0899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease, but an important late sequela after acute pulmonary embolism. Therefore, follow-up after at least three months of sufficient anticoagulation is recommended. Patients with suspected CTEPH should be referred to specialized CTEPH centers for further evaluation and treatment.Three treatment modalities are available: pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and pulmonary hypertension-targeted drugs. The indication for surgery depends mainly on the localization of the pulmonary arterial obstructions. Severe comorbidities as well as advanced age need individual evaluation, but do not present strict exclusion criteria. Multimodal treatments are common practice in inoperable CTEPH. However, treatment decision making in an experienced multidisciplinary team is mandatory.
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Grafham GK, Bambrick M, Houbois C, Mafeld S, Donahoe L, de Perrot M, McInnis MC. Enhancing preoperative assessment in chronic thromboembolic pulmonary hypertension: A comprehensive analysis of interobserver agreement and proximity-based CT pulmonary angiography scoring. Heliyon 2023; 9:e20899. [PMID: 37954325 PMCID: PMC10632681 DOI: 10.1016/j.heliyon.2023.e20899] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/28/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Background Surgical risk in chronic thromboembolic pulmonary hypertension (CTEPH) depends on the proximity of thromboembolism on CT pulmonary angiography (CTPA). We assessed interobserver agreement for the quantification of thromboembolic lesions in CTEPH using a novel CTPA scoring index. Methods Forty CTEPH patients (mean age, 58 ± 16 years; 19 men) with preoperative CTPA who underwent pulmonary endarterectomy (PEA) (08/2020-09/2021) were retrospectively included. Three radiologists scored each CTPA for chronic thromboembolism (occlusions, eccentric thickening, webs) using a 32-vessel model of the pulmonary vasculature, with interobserver agreement evaluated using Fleiss' kappa. CT level of disease was determined by the most proximal chronic thromboembolism: level 1 (main pulmonary artery), 2 (lobar), 3 (segmental) and 4 (subsegmental), and compared to surgical level at PEA. Results Interobserver agreement for CT level of disease was moderate overall (κ = 0.52). Agreement was substantial overall at the main/lobar level (κ, mean = 0.71) when excluding the left upper lobe (κ = 0.17). Though segmental and subsegmental agreement suffered (κ = 0.31), we found substantial agreement for occlusions (κ = 0.72) compared to eccentric thickening (κ = 0.45) and webs (κ = 0.14). Correlation between CT level and surgical level was strong overall (τb = 0.73) and in the right lung (τb = 0.68), but weak in the left lung (τb = 0.42) (p < 0.05). Radiologists often over- and underestimated the proximal extent of disease in right and left lung, respectively. Conclusions CT level of disease demonstrated good agreement between radiologists and was highly predictive of the surgical level in CTEPH. Occlusions were the most reliable sign of chronic thromboembolism and are important in assessing the segmental vasculature.
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Affiliation(s)
- Grace K. Grafham
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marie Bambrick
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Christian Houbois
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Donahoe
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Marc de Perrot
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Micheal C. McInnis
- Division of Cardiothoracic and Vascular Imaging, Joint Department of Medical Imaging, Toronto General Hospital, Toronto, Ontario, Canada
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Qutab S, Alonzo S, Crerar-Gilbert AA, Madden B. An ABC approach to cardiothoracic complications and sequelae of COVID-19: a tertiary centre experience. Clin Med (Lond) 2023; 23:606-610. [PMID: 38065603 PMCID: PMC11046629 DOI: 10.7861/clinmed.2023-0205] [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: 12/18/2023]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has caused unprecedented challenges to healthcare professionals (HCPs) worldwide. HCPs faced an unknown disease causing many complications, including now well-established acute respiratory distress syndrome (ARDS) and pulmonary artery thromboembolic disease, and some not so well known, for instance, tracheobronchomalacia, tracheal tear or dehiscence, granulation tissue formation and pulmonary hypertension. Many of these complications require highly specialist care warranting early recognition of complications and involvement of appropriately trained professionals. Here, we review the complications and sequelae encountered at our tertiary care centre with follow-up data and potential management strategies using the A (Airway), B (Breathing), C (Circulation) approach. This will not only familiarise HCPs with the different complications of COVID-19, but also arm them with a systematic approach to these complications.
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43
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Johnsen SP, Jensen M, Münster AM, Frost L, Harboe L, Poulsen PB, Albertsen IE, Vinter N, Grove EL, Larsen TB. Small-Area Analysis of Treatment and Clinical Outcomes in Patients with Venous Thromboembolism in Denmark: A Nationwide Cohort Study. Thromb Haemost 2023; 123:978-988. [PMID: 37054981 DOI: 10.1055/a-2073-4336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
OBJECTIVES To investigate geographical variation in initiation and extended treatment with anticoagulants and clinical outcomes among patients hospitalized with first-time venous thromboembolism (VTE) in Denmark between 2007 and 2018. METHODS Using nationwide health care registries, we identified all patients with a first-time VTE hospital diagnosis supported by imaging data from 2007 to 2018. Patients were grouped according to residential region (5) and municipality (98) at the time of VTE diagnosis. Cumulative incidence of initiation of and extended (beyond 365 days) anticoagulation treatment as well as clinical outcomes, including recurrent VTE, major bleeding, and all-cause death, were assessed. Sex- and age-adjusted relative risks (RRs) of the outcomes were computed when comparing across individual regions and municipalities. Overall geographic variation was quantified by computing the median RR. RESULTS We identified 66,840 patients with a first-time VTE hospitalization. A difference in initiation of anticoagulation treatment of more than 20 percentage points between regions was observed (range: 51.9-72.4%, median RR: 1.09, 95% confidence interval [CI]: 1.04-1.13). Variation was also observed for extended treatment (range: 34.2-46.9%, median RR: 1.08, 95% CI: 1.02-1.14). The cumulative incidence of recurrent VTE ranged from 3.6 to 5.3% at 1 year (median RR: 1.08, 95% CI: 1.01-1.15). The difference remained after 5 years, and variation was also observed for major bleeding (median RR: 1.09, 95% CI: 1.03-1.15), whereas it appeared smaller for all-cause mortality (median RR: 1.03, 95% CI: 1.01-1.05). CONCLUSION Substantial geographical variation in anticoagulation treatment and clinical outcomes occurs in Denmark. These findings indicate a need for initiatives to ensure uniform high-quality care for all VTE patients.
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Affiliation(s)
- Søren P Johnsen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
| | - Martin Jensen
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Anna Marie Münster
- Unit for Thrombosis Research, Hospital of South West Jutland, Esbjerg, Denmark
| | - Lars Frost
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | | | | | - Ida E Albertsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Nicklas Vinter
- Department of Clinical Medicine, Danish Center for Clinical Health Services Research, Aalborg University and Aalborg University Hospital, Aalborg, Denmark
- Diagnostic Centre, University Research Clinic for Innovative Patient Pathways, Silkeborg Regional Hospital, Silkeborg, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Erik L Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Torben B Larsen
- Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Falster C, Egholm G, Jacobsen N, Poulsen MK, Posth S, Møller JE, Brabrand M, Laursen CB. Multiorgan ultrasonographic findings in patients with pulmonary embolism at diagnosis and clinical follow-up: a proof of concept study. J Ultrasound 2023; 26:663-672. [PMID: 36114986 PMCID: PMC10468447 DOI: 10.1007/s40477-022-00716-w] [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: 06/24/2022] [Accepted: 08/04/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The purpose of this descriptive feasibility study was to assess the clinical impact and feasibility of conducting a multiorgan ultrasound examination of patients with pulmonary embolism at both time of diagnosis and at clinical follow-up. METHODS Hemodynamically stable patients with pulmonary embolism verified by CT pulmonary angiography or ventilation perfusion scintigraphy were eligible for inclusion. Enrolled patients underwent multiorgan ultrasound investigation encompassing echocardiography supplemented with focused lung and deep venous ultrasound emphasizing right ventricular strain, subpleural consolidations and presence of deep venous thrombi. Identical investigations were conducted at 3 months follow-up. The presence of ultrasonographic findings at diagnosis and follow-up was compared and the clinical impact of any remaining pathology or strain was described. RESULTS Twenty-one patients were enrolled in the study of whom 20 survived to attend follow-up. Mean age was 62 ± 15 years and 48% were female. At diagnosis, the most prevalent ultrasonographic findings were subpleural consolidations in 11 patients and right ventricular dilation in eight. At follow-up, signs of right ventricular strain had resolved in all patients. However, in one patient, no resolution was seen in a subpleural consolidation observed at the time of pulmonary embolism diagnosis, resulting in referral to a chest CT. Additionally, one patient exhibited residual deep venous thrombotic material, leading to prolongation of anticoagulative treatment. CONCLUSION In patients with pulmonary embolism, multiorgan ultrasound is feasible in follow-up and adequately powered studies should determine the clinical utility of such an approach.
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Affiliation(s)
- Casper Falster
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark.
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
- OPEN, Open Patient Data Explorative Network, Odense University Hospital, Odense, Region of Southern Denmark, Denmark.
| | - Gro Egholm
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Niels Jacobsen
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Mikael K Poulsen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Stefan Posth
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Jacob E Møller
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Christian B Laursen
- Department of Respiratory Medicine, Odense University Hospital, Entrance 122, 5000, Odense C, Denmark
- Odense Respiratory Research Unit (ODIN), Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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45
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Wiedenroth CB, Pruefer D, Adameit MSD, Mayer E, Guth S. Chronic thromboembolic pulmonary hypertension-medical, interventional, and surgical therapy. Herz 2023; 48:280-284. [PMID: 37186021 DOI: 10.1007/s00059-023-05172-8] [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] [Accepted: 03/02/2023] [Indexed: 05/17/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is an important late sequela of pulmonary embolism and a common form of pulmonary hypertension. Currently, three specific treatment modalities are available: pulmonary endarterectomy, balloon pulmonary angioplasty, and targeted medical therapy. The treatment decision depends mainly on the exact localization of the underlying pulmonary arterial obstructions. Pulmonary endarterectomy is the gold standard treatment of CTEPH. For inoperable patients, riociguat and treprostinil are approved. In addition, interventional therapy is recommended if appropriate target lesions are proven. Evaluation and treatment of patients with CTEPH in experienced centers are mandatory.
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Affiliation(s)
- Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany.
| | - Diethard Pruefer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Miriam S D Adameit
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Eckhard Mayer
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
| | - Stefan Guth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Center, Benekestr. 2-8, 61231, Bad Nauheim, Germany
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46
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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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Fernandes TM, Kim NH, Kerr KM, Auger WR, Fedullo PF, Poch DS, Yang J, Papamatheakis DG, Alotaibi M, Bautista MA, Pretorius VG, Madani MM. Distal vessel pulmonary thromboendarterectomy: Results from a single institution. J Heart Lung Transplant 2023; 42:1112-1119. [PMID: 37024310 DOI: 10.1016/j.healun.2023.02.1500] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 02/16/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023] Open
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is primarily managed by pulmonary thromboendarterectomy (PTE). As advanced surgical techniques permit resection at the segmental and subsegmental level, PTE can now be curative for CTEPH mostly involving the distal pulmonary arteries. METHODS Between January 2017 and June 2021, consecutive patients undergoing PTE were categorized according to the most proximal level of chronic thrombus resection: Level I (main pulmonary artery), Level II (lobar), Level III (segmental) and Level IV (subsegmental). Proximal disease patients (any Level I or II) were compared to distal disease (Level III or IV bilaterally) patients. Demographics, medical history, preoperative pulmonary hemodynamics, and immediate postoperative outcomes were obtained for each group. RESULTS During the study period, 794 patients underwent PTE, 563 with proximal disease and 231 with distal disease. Patients with distal disease more frequently had a history of an indwelling intravenous device, splenectomy, upper extremity thrombosis or use thyroid replacement and less often had prior lower extremity thrombosis or hypercoagulable state. Despite more use of PAH-targeted medications in the distal disease group (63.2% vs 50.1%, p < 0.001), preoperative hemodynamics were similar. Both patient groups exhibited significant improvements in pulmonary hemodynamics postoperatively with comparable in-hospital mortality rates. Compared to proximal disease, a lower percentage of patients with distal disease showed residual pulmonary hypertension (3.1% vs 6.9%, p = 0.039) and airway hemorrhage (3.0% vs 6.6%, p = 0.047) postoperatively. CONCLUSIONS Thromboendarterectomy for distal (segmental and subsegmental) CTEPH is technically feasible and may result in favorable pulmonary hemodynamic outcomes, without increased mortality or morbidity.
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Affiliation(s)
- Timothy M Fernandes
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Nick H Kim
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Kim M Kerr
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - William R Auger
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Peter F Fedullo
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - David S Poch
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Jenny Yang
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California; San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Demosthenes G Papamatheakis
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Mona Alotaibi
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Marie A Bautista
- San Diego Health System, Division of Pulmonary, Critical Care and Sleep Medicine, University of California, La Jolla, California
| | - Victor G Pretorius
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California
| | - Michael M Madani
- San Diego Health System, Division of Cardiovascular and Thoracic Surgery, University of California, La Jolla, California.
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Otero R, Lobo JL, López R, Fernández C, Jiménez D, Muriel A, Alfonso M, Ballaz A, Núñez-Ares A, Rodríguez-Matute C, de Miguel-Díez J, Rodríguez-Chiaradía DA, Alcalde M, Elías T, Jara-Palomares L, Rivas A, Alonso Á, García-Ortega A, Sancho T, Morillo R, García-Bragado F, Hernández-Blasco L, Uresandi F, Madridano O, Agüero R, Monreal M. Feasibility of a screening algorithm for chronic thromboembolic pulmonary hypertension: The OSIRIS study. Thromb Res 2023; 228:1-9. [PMID: 37263121 DOI: 10.1016/j.thromres.2023.05.005] [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: 01/15/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a long-term sequel to pulmonary embolism (PE) whose incidence varies according to different published studies. We have carried out this study to determine its incidence within 2 years after index pulmonary embolism and to study limitations to an early diagnosis. MATERIAL AND METHODS OSIRIS is a multicentre, longitudinal cohort study. Patients were followed for 3, 6, 12, and 24 months after pulmonary embolism using a structured three-step algorithm. A physician-centered questionnaire at least one positive response in a screening proceeded to the second step, transthoracic echocardiography. The third step consisted of ventilation/perfusion lung scintigraphy and right heart catheterisation. A transthoracic echocardiography was performed in patients without positive response in the screening questionnaire after 2 years. CTEPH diagnosis required haemodynamic confirmation by right heart catheterisation and mismatched perfusion defects on lung scintigraphy. RESULTS A total of 1191 patients were enrolled in 18 Spanish hospitals. Cumulative CTEPH incidence after 2-years PE was: 2.49 % (95 % CI: 1.68-3.56) and the incidence rate of CTEPH was 1.1 cases per 1000 person-months (95 % CI: 0.725; 1.60). The CTEPH algorithm presented a lack of adherence of 29 %; patient and physician preferences posed barriers to the triage algorithm The screening questionnaire, in patients who completed the follow-up, shows a specificity of 91.3 % (89.0-93.2 %) and negative predictive value of 99.4 % (98.4-99.8 %).. CONCLUSIONS OSIRIS provides practiced clinical based data on the chronic thromboembolic pulmonary hypertension incidence and identified barriers to the implementation of a 3-step triage algorithm for its detection. CLINICAL TRIAL REGISTRATION clinicaltrials.gov identifier: NCT03134898.
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Affiliation(s)
- Remedios Otero
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain.
| | - José Luis Lobo
- Hospital de Araba, Vitoria-Gasteiz, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Raquel López
- Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | | | - David Jiménez
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Alfonso Muriel
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
| | | | | | | | | | | | | | | | - Teresa Elías
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain
| | - Luis Jara-Palomares
- Hospital Universitario Virgen del Rocío, Instituto de Biomedicina (IBIS), Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | | | | | - Raquel Morillo
- Hospital Universitario Ramón y Cajal y Universidad de Alcalá, IRYCIS, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | | | - Olga Madridano
- Hospital Infanta Sofía, San Sebastían de los Reyes, Madrid, Spain
| | - Ramón Agüero
- Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | - Manuel Monreal
- Hospital Universitario Germans Trias i Pujol, Badalona, Spain
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Yang J, Madani MM, Mahmud E, Kim NH. Evaluation and Management of Chronic Thromboembolic Pulmonary Hypertension. Chest 2023; 164:490-502. [PMID: 36990148 PMCID: PMC10410247 DOI: 10.1016/j.chest.2023.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension and right heart failure. CTEPH (group 4 pulmonary hypertension) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved acute pulmonary embolism. CTEPH also may present without prior VTE history, which can contribute to its underrecognition. The true incidence of CTEPH is unclear, but is estimated to be approximately 3% after acute pulmonary embolism. V˙/Q˙ scintigraphy is the best screening test for CTEPH, with CT scan imaging and other advanced imaging methods now playing a larger role in disease detection and confirmation. Perfusion defects on V˙/Q˙ scintigraphy in the setting of pulmonary hypertension are suggestive of CTEPH, but pulmonary angiography and right heart catheterization are required for confirmation and treatment planning. CTEPH potentially is curative with pulmonary thromboendarterectomy surgery, with mortality rates of approximately 2% at expert centers. Advances in operative techniques are allowing more distal endarterectomies to be performed successfully with favorable outcomes. However, more than one-third of patients may be considered inoperable. Although these patients previously had minimal therapeutic options, effective treatments now are available with pharmacotherapy and balloon pulmonary angioplasty. Diagnosis of CTEPH should be considered in all patients with suspicion of pulmonary hypertension. Treatments for CTEPH have advanced with improvements in outcomes for both operable and inoperable patients. Therapy should be tailored based on multidisciplinary team evaluation to ensure optimal treatment response.
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Affiliation(s)
- Jenny Yang
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, CA
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA
| | - Nick H Kim
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA.
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Çınar C, Yıldızeli ŞO, Balcan B, Yıldızeli B, Mutlu B, Peker Y. Determinants of Severe Nocturnal Hypoxemia in Adults with Chronic Thromboembolic Pulmonary Hypertension and Sleep-Related Breathing Disorders. J Clin Med 2023; 12:4639. [PMID: 37510754 PMCID: PMC10380264 DOI: 10.3390/jcm12144639] [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: 06/18/2023] [Revised: 07/05/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVES We aimed to investigate the occurrence of sleep-related breathing disorders (SRBDs) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and addressed the effect of pulmonary hemodynamics and SRBD indices on the severity of nocturnal hypoxemia (NH). METHODS An overnight polysomnography (PSG) was conducted in patients with CTEPH, who were eligible for pulmonary endarterectomy. Pulmonary hemodynamics (mean pulmonary arterial pressure (mPAP), pulmonary arterial wedge pressure (PAWP), pulmonary vascular resistance (PVR) measured with right heart catheterization (RHC)), PSG variables (apnea-hypopnea index (AHI)), lung function and carbon monoxide diffusion capacity (DLCO) values, as well as demographics and comorbidities were entered into a logistic regression model to address the determinants of severe NH (nocturnal oxyhemoglobin saturation (SpO2) < 90% under >20% of total sleep time (TST)). SRBDs were defined as obstructive sleep apnea (OSA; as an AHI ≥ 15 events/h), central sleep apnea with Cheyne-Stokes respiration (CSA-CSR; CSR pattern ≥ 50% of TST), obesity hypoventilation syndrome (OHS), and isolated sleep-related hypoxemia (ISRH; SpO2 < 88% under >5 min without OSA, CSA, or OHS). RESULTS In all, 50 consecutive patients (34 men and 16 women; mean age 54.0 (SD 15.1) years) were included. The average mPAP was 43.8 (SD 16.8) mmHg. SRBD was observed in 40 (80%) patients, of whom 27 had OSA, 2 CSA-CSR, and 11 ISRH. None had OHS. Severe NH was observed in 31 (62%) patients. Among the variables tested, age (odds ratio (OR) 1.08, 95% confidence interval [CI] 1.01-1.15; p = 0.031), mPAP (OR 1.11 [95% CI 1.02-1.12; p = 0.012]), and AHI (OR 1.17 [95% CI 1.02-1.35; p = 0.031]) were independent determinants of severe NH. CONCLUSIONS Severe NH is highly prevalent in patients with CTEPH. Early screening for SRBDs and intervention with nocturnal supplemental oxygen and/or positive airway pressure as well as pulmonary endarterectomy may reduce adverse outcomes in patients with CTEPH.
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Affiliation(s)
- Caner Çınar
- Department of Pulmonary Medicine, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Şehnaz Olgun Yıldızeli
- Department of Pulmonary Medicine, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Baran Balcan
- Department of Pulmonary Medicine, School of Medicine, Koç University, Istanbul 34450, Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Bülent Mutlu
- Department of Cardiology, School of Medicine, Marmara University, Istanbul 34854, Turkey
| | - Yüksel Peker
- Department of Pulmonary Medicine, School of Medicine, Koç University, Istanbul 34450, Turkey
- Department of Molecular and Clinical Medicine, University of Gothenburg, 405 30 Gothenburg, Sweden
- Department of Respiratory Medicine and Allergology, Faculty of Medicine, Lund University, 221 00 Lund, Sweden
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA
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