|
1
|
Páez-Carpio A, Zarco FX, Serrano E, Vollmer I, Puig J, Barberà JA, Gómez FM, Blanco I. Cone beam CT pulmonary angiography in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension during the program initiation period. Clin Radiol 2025; 84:106847. [PMID: 40058193 DOI: 10.1016/j.crad.2025.106847] [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: 07/25/2024] [Revised: 01/27/2025] [Accepted: 02/09/2025] [Indexed: 04/20/2025]
Abstract
AIM Cone beam CT pulmonary angiography (CBCT-PA) has proven to be a valuable technique during balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH) in established centres. This study aimed to demonstrate the safety and efficacy of CBCT-PA-guided BPA for CTEPH during the initial period of a BPA program. CBCT-PA improves procedural accuracy by visualising distal thromboembolic lesions and providing real-time guidance, which is critical during program initiation. MATERIALS AND METHODS This single-centre, single-arm study prospectively evaluated patients with CTEPH undergoing BPA from 2017 to 2022. Outcomes of interest included pre-BPA and post-BPA 6-minute walking distance, New York Heart Association Functional Classification (NYHA-FC), mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), N-terminal pro B-type natriuretic peptide (NT-proBNP), and BPA-related adverse events (AEs). Statistical analysis compared pre-BPA and post-BPA results. CBCT-PA was used for three-dimensional (3D) vascular mapping and precise lesion targeting. RESULTS Ninety BPA sessions were performed on 19 patients under CBCT-PA guidance. Significant improvements were observed in mPAP (37.0 mmHg [interquartile range (IQR): 28.0-46.0] vs 25.5 [IQR: 22.8-31.5]; P<0.001), PVR (5.5 Wood units [IQR: 3.4-8.5] vs 3.3 [IQR: 2.7-4.6]; P < 0.001), NYHA-FC I-II rate (8 [42%] vs 18 [94%]; P = 0.04), and NT-proBNP (165 pg/mL [IQR: 82-1146] vs 127.0 [IQR: 57-216]; P = 0.014). Overall AE rate was 14.4%, and major AE rate was 7.7% (all Cardiovascular and Interventional Radiology Society of Europe [CIRSE] grade 3). The haemoptysis rate was 4.4%. No periprocedural deaths were reported. CONCLUSION BPA performed under CBCT-PA guidance appeared to be an effective and safe approach in the program's initial period, helping achieving similar results as established centres.
Collapse
Affiliation(s)
- A Páez-Carpio
- Department of Medical Imaging, University of Toronto, Toronto M5T 1W7, ON, Canada; Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona 08036, Spain.
| | - F X Zarco
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain.
| | - E Serrano
- Department of Radiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat 08907, Spain.
| | - I Vollmer
- Department of Radiology, Vall d'Hebron University Hospital, Barcelona 08035, Spain.
| | - J Puig
- Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain.
| | - J A Barberà
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain.
| | - F M Gómez
- Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain.
| | - I Blanco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Department of Pulmonary Medicine, Hospital Clínic Barcelona, Barcelona 08036, Spain; Biomedical Research Networking Centre on Respiratory Diseases (CIBERES), Madrid, Spain.
| |
Collapse
|
|
2
|
Páez-Carpio A, Gómez FM, Maschke S, Warren B, Martínez J, Meyer BC, Mafeld S. Cone Beam-CT pulmonary angiography in balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: A review of technical parameters and benefits. Eur J Radiol 2025; 186:112047. [PMID: 40154013 DOI: 10.1016/j.ejrad.2025.112047] [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: 11/21/2024] [Revised: 02/13/2025] [Accepted: 03/07/2025] [Indexed: 04/01/2025]
Abstract
Balloon pulmonary angioplasty (BPA) has emerged as a crucial intervention for patients with chronic thromboembolic pulmonary hypertension (CTEPH) unsuitable for surgery. However, the complexity of pulmonary vasculature in CTEPH necessitates advanced imaging techniques for precise procedural diagnosis and planning. This review highlights the role of cone-beam CT pulmonary angiography (CBCT-PA) in enhancing the visualization and characterization of the pulmonary vasculature. Specific advantages over traditional imaging methods like digital subtraction angiography and CT pulmonary angiography are discussed. CBCT-PA provides detailed three-dimensional roadmaps, optimizing procedural parameters that can improve safety and efficacy. Despite these advantages, standardized protocols for CBCT-PA are lacking, underscoring the need for structured guidelines to fully integrate this technology into BPA programs for better clinical outcomes in CTEPH patients.
Collapse
Affiliation(s)
- Alfredo Páez-Carpio
- Department of Medical Imaging, University of Toronto, Toronto M5T 1W7 ON, Canada; Department of Vascular and Interventional Radiology, University Health Network, Toronto, ON M5G 2N2, Canada; Department of Radiology, CDI, Hospital Clínic Barcelona, Barcelona 08036, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona 08036, Spain; Faculty of Medicine and Health Sciences, Universitat de Barcelona, Barcelona 08036, Spain
| | - Fernando M Gómez
- Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain
| | - Sabine Maschke
- Hannover Medical School - Institute for Diagnostic and Interventional Radiology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Blair Warren
- Department of Medical Imaging, University of Toronto, Toronto M5T 1W7 ON, Canada; Department of Vascular and Interventional Radiology, University Health Network, Toronto, ON M5G 2N2, Canada
| | - José Martínez
- Department of Radiology, Hospital Universitari i Politècnic La Fe, València 46026, Spain
| | - Bernhard C Meyer
- Hannover Medical School - Institute for Diagnostic and Interventional Radiology, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, Toronto M5T 1W7 ON, Canada; Department of Vascular and Interventional Radiology, University Health Network, Toronto, ON M5G 2N2, Canada.
| |
Collapse
|
|
3
|
Souza FSDF, Ferreira MG, Melo IA, de Sá MFL, Loureiro CMC, Abreu R, de Carvalho PHA, Viana MDS, Oliveira V, Ritt LEF. Balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension: short- and long-term results from a cohort in Brazil. J Bras Pneumol 2025; 50:e20240147. [PMID: 39813496 PMCID: PMC11665283 DOI: 10.36416/1806-3756/e20240147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 11/06/2024] [Indexed: 01/18/2025] Open
Abstract
OBJECTIVE A significant number of patients with chronic thromboembolic pulmonary hypertension (CTEPH) are not eligible for pulmonary endarterectomy and may be treated with balloon pulmonary angioplasty (BPA). Although BPA programs have recently been developed in Brazil, no results have yet been published. The objective of this study was to assess the clinical and hemodynamic progression of the first patients treated with BPA at our center. METHODS This was an observational study of 23 patients with CTEPH enrolled in the BPA program of a specialized center in Brazil between 2015 and 2020. RESULTS After a mean of 5.6 ± 1.3 sessions and 11 ± 2.8 treated segments/patient (at a mean of 6.7 ± 2.9 months post-BPA), there was a 26% decrease in mean pulmonary artery pressure (51 ± 11 vs. 38 ± 11 mmHg; p < 0.0001), a 43% decrease in pulmonary vascular resistance (10 ± 3.7 vs. 5.7 ± 3.3 WU; p < 0.0001), and a 22.5% increase in the cardiac index (2.38 ± 0.6 vs. 2.95 ± 0.6 L/min/m2; p < 0.0001). There was an increase in the six-minute walk distance and an improvement in functional class. Acute lung injury with clinical manifestations was observed after 7% of the BPA sessions. None of the patients required intubation. During a mean outpatient follow-up period of 38 ± 22 months, two patients were referred for additional BPA sessions due to clinical worsening and new hospitalizations. Two deaths were recorded (due to CTEPH progression and gastrointestinal bleeding, respectively). CONCLUSIONS Among this first group of patients treated with BPA in Brazil, there was significant short- and long-term clinical improvement, together with a low frequency of complications.
Collapse
Affiliation(s)
- Fabio Solano de Freitas Souza
- . Unidade de Intervenção Cardiovascular, Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador (BA) Brasil
- . Instituto D’Or de Pesquisa e Ensino - IDOR - Hospital Cárdio-Pulmonar, Rede D’Or, Salvador (BA) Brasil
| | - Marcelo Gottschald Ferreira
- . Unidade de Intervenção Cardiovascular, Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador (BA) Brasil
- . Instituto D’Or de Pesquisa e Ensino - IDOR - Hospital Cárdio-Pulmonar, Rede D’Or, Salvador (BA) Brasil
| | | | - Marta Ferreira Leite de Sá
- . Centro de Referência de Hipertensão Pulmonar, Hospital Especializado Octávio Mangabeira, Salvador (BA) Brasil
| | - Camila Melo Coelho Loureiro
- . Centro de Referência de Hipertensão Pulmonar, Hospital Especializado Octávio Mangabeira, Salvador (BA) Brasil
- . Serviço de Pneumologia, Hospital Santa Izabel, Santa Casa da Misericórdia, Salvador (BA) Brasil
| | - Rosalvo Abreu
- . Serviço de Pneumologia, Hospital Santa Izabel, Santa Casa da Misericórdia, Salvador (BA) Brasil
| | - Paulo Henrique Alves de Carvalho
- . Serviço de Anestesiologia, Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador (BA) Brasil
| | - Mateus dos Santos Viana
- . Unidade de Intervenção Cardiovascular, Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador (BA) Brasil
- . Instituto D’Or de Pesquisa e Ensino - IDOR - Hospital Cárdio-Pulmonar, Rede D’Or, Salvador (BA) Brasil
- . Escola Bahiana de Medicina e Saúde Publica, Salvador (BA) Brasil
| | - Valdemar Oliveira
- . Instituto D’Or de Pesquisa e Ensino - IDOR - Hospital Cárdio-Pulmonar, Rede D’Or, Salvador (BA) Brasil
| | - Luiz Eduardo Fonteles Ritt
- . Instituto D’Or de Pesquisa e Ensino - IDOR - Hospital Cárdio-Pulmonar, Rede D’Or, Salvador (BA) Brasil
- . Escola Bahiana de Medicina e Saúde Publica, Salvador (BA) Brasil
| |
Collapse
|
|
4
|
Serrano E, Valcárcel José J, Páez-Carpio A, Matute-González M, Werner MF, López-Rueda A. Cone Beam computed tomography (CBCT) applications in image-guided minimally invasive procedures. RADIOLOGIA 2025; 67:38-53. [PMID: 39978879 DOI: 10.1016/j.rxeng.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/07/2023] [Indexed: 02/22/2025]
Abstract
Cone-Beam computed tomography (CBCT) obtains three-dimensional images using a two-dimensional detector. The use of CBCT in treatment planning and evaluation increases the safety and efficacy of minimally invasive procedures. This article reviews the technical considerations, main clinical applications, and future directions of CBCT in vascular and interventional radiology and interventional neuroradiology.
Collapse
Affiliation(s)
- E Serrano
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular Intervencionista, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - J Valcárcel José
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular Intervencionista, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, Spain
| | - A Páez-Carpio
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular e Intervencionista, Hospital Clínic de Barcelona, Barcelona, Spain
| | - M Matute-González
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular e Intervencionista, Hospital Clínic de Barcelona, Barcelona, Spain
| | - M F Werner
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular e Intervencionista, Hospital Clínic de Barcelona, Barcelona, Spain
| | - A López-Rueda
- Centro de Diagnóstico por la Imagen, Sección de Radiología Vascular e Intervencionista, Hospital Clínic de Barcelona, Barcelona, Spain.
| |
Collapse
|
|
5
|
Shah KP, Lee C, McBane RD, Piazza G, Frantz RP, Houghton DE, Casanegra AI, Henkin S. Post-Pulmonary Embolism Syndrome-A Diagnostic Dilemma and Challenging Management. Mayo Clin Proc 2024; 99:1965-1982. [PMID: 39520416 DOI: 10.1016/j.mayocp.2024.07.008] [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: 04/24/2024] [Revised: 06/06/2024] [Accepted: 07/10/2024] [Indexed: 11/16/2024]
Abstract
Historically, research on pulmonary embolism (PE) management has focused on short-term outcomes, such as acute cardiovascular collapse, change in right ventricular function, and in-hospital mortality. However, long-standing functional impairments from acute PE occur in up to half of all patients. This chronic syndrome has been termed the post-PE syndrome, which describes patients who have persistent or worsening symptoms, functional limitations, and cardiorespiratory impairment not explained by a comorbid condition. Diagnosis and management are challenging, and post-PE syndrome remains an underrecognized and undertreated condition. This review seeks to increase awareness of the syndrome that affects a significant portion of PE survivors. The epidemiology, pathophysiology, and clinical features are discussed, followed by a description of imaging findings and management options across the entire spectrum of post-PE syndrome.
Collapse
Affiliation(s)
- Kajal P Shah
- Section of Cardiovascular Medicine, Heart and Vascular Center, Dartmouth Hitchcock Medical Center, Lebanon, NH
| | - Christopher Lee
- Division of Cardiology, University of California San Francisco Health, San Francisco
| | - Robert D McBane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ana I Casanegra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Stanislav Henkin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
| |
Collapse
|
|
6
|
Simeone B, Maggio E, Schirone L, Rocco E, Sarto G, Spadafora L, Bernardi M, Ambrosio LD, Forte M, Vecchio D, Valenti V, Sciarretta S, Vizza CD. Chronic thromboembolic pulmonary hypertension: the diagnostic assessment. Front Cardiovasc Med 2024; 11:1439402. [PMID: 39309600 PMCID: PMC11412851 DOI: 10.3389/fcvm.2024.1439402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Accepted: 08/28/2024] [Indexed: 09/25/2024] Open
Abstract
Chronic Thromboembolic Pulmonary Hypertension (CTEPH) presents a significant diagnostic challenge due to its complex and often nonspecific clinical manifestations. This review outlines a comprehensive approach to the diagnostic assessment of CTEPH, emphasizing the importance of a high index of suspicion in patients with unexplained dyspnea or persistent symptoms post-acute pulmonary embolism. We discuss the pivotal role of multimodal imaging, including echocardiography, ventilation/perfusion scans, CT pulmonary angiography, and magnetic resonance imaging, in the identification and confirmation of CTEPH. Furthermore, the review highlights the essential function of right heart catheterization in validating the hemodynamic parameters indicative of CTEPH, establishing its definitive diagnosis. Advances in diagnostic technologies and the integration of a multidisciplinary approach are critical for the timely and accurate diagnosis of CTEPH, facilitating early therapeutic intervention and improving patient outcomes. This manuscript aims to equip clinicians with the knowledge and tools necessary for the efficient diagnostic workflow of CTEPH, promoting awareness and understanding of this potentially treatable cause of pulmonary hypertension.
Collapse
Affiliation(s)
- Beatrice Simeone
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Enrico Maggio
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Erica Rocco
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Gianmarco Sarto
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luigi Spadafora
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Marco Bernardi
- Department of Cardiology, ICOT Istituto Marco Pasquali, Latina, Italy
| | - Luca D’ Ambrosio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Maurizio Forte
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
| | - Daniele Vecchio
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Valentina Valenti
- Department of Cardiology, Santa Maria Goretti Hospital, Latina, Italy
- Department of Cardiology, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Sebastiano Sciarretta
- Department of Angiocardioneurology, IRCCS Neuromed, Pozzilli, Italy
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy
| | - Carmine Dario Vizza
- Department of Cardiovascular and Respiratory Sciences, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
|
7
|
Lang IM. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Clinical Outcomes. Eur Cardiol 2023. [DOI: 10.15420/ecr.2022.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare major vessel pulmonary vascular disease that is characterised by fibrotic obstructions deriving from an organised clot. Recent advances in treatments for CTEPH have significantly improved outcomes. Apart from classical surgical pulmonary endarterectomy, balloon pulmonary angioplasty (BPA) and vasodilator drugs that were tested in randomised controlled trials of non-operable patients are now available. In Europe, CTEPH affects males and females equally. In the first European CTEPH Registry, women with CTEPH underwent pulmonary endarterectomy less frequently than men, especially at low-volume centres. In Japan, CTEPH is more common in females and is predominantly treated by BPA. More data on gender-specific outcomes are expected from the results of the International BPA Registry (NCT03245268).
Collapse
Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
|
8
|
Higuchi S, Horinouchi H, Aoki T, Nishii T, Ota Y, Ueda J, Tsuji A, Ota H, Ogo T, Fukuda T. Balloon Pulmonary Angioplasty in the Management of Chronic Thromboembolic Pulmonary Hypertension. Radiographics 2022; 42:1881-1896. [DOI: 10.1148/rg.210102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Satoshi Higuchi
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Hiroki Horinouchi
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Tatsuo Aoki
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Tatsuya Nishii
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Yasutoshi Ota
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Jin Ueda
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Akihiro Tsuji
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Hideki Ota
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Takeshi Ogo
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| | - Tetsuya Fukuda
- From the Departments of Radiology (S.H., H.H., T.N., Y.O., T.F.) and Cardiovascular Medicine (T.A., J.U., A.T., T.O.), National Cerebral and Cardiovascular Center, 6-1 Kishibeshinmachi, Suita, Osaka 564-8565, Japan; and Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan (S.H., H.O.)
| |
Collapse
|
|
9
|
Poch DS, Mahmud E, Patel M, Papamatheakis D, Fernandes T, Kerr K, Yang J, Pretorius V, Madani MM, Kim NH. Patient selection for balloon pulmonary angioplasty: Six-year results from a high volume PTE surgical center. Pulm Circ 2022; 12:e12148. [PMID: 36325508 PMCID: PMC9618287 DOI: 10.1002/pul2.12148] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 08/17/2022] [Accepted: 09/12/2022] [Indexed: 11/09/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of incompletely resolved pulmonary emboli (PE) that lead to chronic right heart failure. The two mechanical treatment options are pulmonary thromboendarterectomy (PTE) and balloon pulmonary angioplasty (BPA). There are no formal criteria for BPA patient selection and treatment decisions vary according to a center's experience with BPA and PTE. We performed a retrospective review of consecutive patients treated with PTE and BPA at UCSD from March 2015 to 2021. Clinical and hemodynamic data were collected. Patients were categorized according to the rationale for BPA. One hundred fifty three patients underwent 643 BPA sessions, and 1104 patients underwent PTE. Patients selected for PTE had worse baseline hemodynamics with mean pulmonary artery pressure 41.1 ± 11.7 versus 34.6 ± 11.2 mmHg, p < 0.001. 59% of patients selected for BPA had surgically inaccessible disease, 21% had residual CTEPH after PTE, 10% had a discordance between disease burden and symptoms/hemodynamics, 7% had comorbidities that prevented PTE and 3% refused PTE surgery. 28% of patients who underwent PTE had exclusively level III or IV disease based on surgical specimen. There were no BPA procedure-related mortalities and minor pulmonary vascular complication rates during BPA were 9.2%. The most common reason for BPA selection was surgically inaccessible disease followed by residual CTEPH after PTE. Almost one third of patients who underwent PTE had exclusively distal disease by surgical criteria and might have been directed to BPA at a less experienced surgical center.
Collapse
Affiliation(s)
- David S. Poch
- Division of Pulmonary and Critical CareUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Ehtisham Mahmud
- Division of Cardiovascular MedicineUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Mitul Patel
- Division of Cardiovascular MedicineUniversity of California, San DiegoLa JollaCaliforniaUSA
| | | | - Timothy Fernandes
- Division of Pulmonary and Critical CareUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Kim Kerr
- Division of Pulmonary and Critical CareUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Jenny Yang
- Division of Pulmonary and Critical CareUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Victor Pretorius
- Division of Cardiovascular and Thoracic SurgeryUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Michael M. Madani
- Division of Cardiovascular and Thoracic SurgeryUniversity of California, San DiegoLa JollaCaliforniaUSA
| | - Nick H. Kim
- Division of Pulmonary and Critical CareUniversity of California, San DiegoLa JollaCaliforniaUSA
| |
Collapse
|
|
10
|
Update on balloon pulmonary angioplasty for treatment of chronic thromboembolic pulmonary hypertension. Curr Opin Pulm Med 2022; 28:369-374. [PMID: 35938199 DOI: 10.1097/mcp.0000000000000898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To provide an update on balloon pulmonary angioplasty (BPA) for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a pulmonary vascular disease that is characterized by fibro-thrombotic material mechanically obliterating major pulmonary arteries, resulting in increased pulmonary vascular resistance (PVR), progressive pulmonary hypertension (PH) combined with a microscopic pulmonary vasculopathy [1▪▪], right ventricular (RV) failure [2] and premature death. RECENT FINDINGS Data from a most recent CTEPH European registry (2015 and 2016) suggest significantly improved survival [3▪] of CTEPH patients compared with survival in the eighties [4], or with data from 2007 and 2009 [5]. Pulmonary endarterectomy (PEA) is still the gold-standard therapy for CTEPH [6,7]. However, only around two thirds of all CTEPH patients are amenable to surgery [3▪,5]. Patients not suitable for PEA and treated conservatively have a poor prognosis [8]. BPA may have a role for this particular group of patients. [9-11]. Currently, BPA programs are available in many countries, with excellent results at expert centers [12-15,16▪,17,18▪▪]. Based on recent data, BPA seems to have a greater impact on symptomatic and hemodynamic improvement than medical therapy with riociguat alone [15]. SUMMARY The evidence favoring BPA is growing, but there is still a lack of published controlled trials. In addition, treatment concepts including indication, technical performance, use of PH-targeted medication, and the concept of follow-up vary between centers. In addition, there is a significant learning curve impacting outcomes [13]. The data from the International BPA registry will provide answers for some of the open questions.
Collapse
|
|
11
|
Nakano Y, Adachi S, Nishiyama I, Yasuda K, Imai R, Yoshida M, Iwano S, Kondo T, Murohara T. Usefulness of a refined computed tomography imaging method to assess the prevalence of residual pulmonary thrombi in patients 1 year after acute pulmonary embolism: The Nagoya PE study. J Thromb Haemost 2022; 20:888-898. [PMID: 35000288 PMCID: PMC9303750 DOI: 10.1111/jth.15636] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/04/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Post-pulmonary embolism (PE) syndrome is an important clinical condition that can affect the long-term prognosis after acute PE. OBJECTIVE We aimed to evaluate the prevalence of residual pulmonary thrombi and the thrombotic burden 1 year after acute PE, by using our refined computed tomography (CT) imaging method. PATIENTS/METHODS In this prospective study, patients diagnosed with acute PE were recruited and examinations were conducted at 1 month, 6 months, and 1 year. Especially at 1 year, patients were evaluated multifacetedly, including by laboratory tests, quality-of-life, 6-min walking test, and enhanced CT. RESULTS Fifty-two patients were enrolled. Two patients (3.8%) developed chronic thromboembolic pulmonary hypertension. A total of 43 patients completed evaluation at 1 year, among whom (74%) had residual thrombi, with a median modified CT obstruction index (mCTOI) of 10.7%. In multivariate analysis, residual thrombi at 1 month was the only factor significantly related to residual thrombi at 1 year (odds ratio, 103.4; 95% confidence interval, 4.2-2542.1). The tricuspid regurgitation pressure gradient ≥60 mmHg and left ventricular end-diastolic dimension at diagnosis were significantly related to mCTOI at 1 year (β = 0.367, P = .003; and β = -0.435, P = .001, respectively). CONCLUSIONS Using our improved CT imaging protocol, we found a high prevalence of residual thrombi 1 year after acute PE. Furthermore, right ventricular overload was related to the thrombotic burden. The long-term treatment strategy of acute PE could be modified to include precise CT imaging.
Collapse
Affiliation(s)
- Yoshihisa Nakano
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Shiro Adachi
- Department of CardiologyNagoya University HospitalNagoyaJapan
| | - Itsumure Nishiyama
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | | | - Ryo Imai
- Department of CardiologyNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | | | - Shingo Iwano
- Department of RadiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Takahisa Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
- Department of CardiologyNational Hospital Organization Nagoya Medical CenterNagoyaJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| |
Collapse
|
|
12
|
Delcroix M, Torbicki A, Gopalan D, Sitbon O, Klok FA, Lang I, Jenkins D, Kim NH, Humbert M, Jais X, Vonk Noordegraaf A, Pepke-Zaba J, Brénot P, Dorfmuller P, Fadel E, Ghofrani HA, Hoeper MM, Jansa P, Madani M, Matsubara H, Ogo T, Grünig E, D'Armini A, Galie N, Meyer B, Corkery P, Meszaros G, Mayer E, Simonneau G. ERS statement on chronic thromboembolic pulmonary hypertension. Eur Respir J 2021; 57:13993003.02828-2020. [PMID: 33334946 DOI: 10.1183/13993003.02828-2020] [Citation(s) in RCA: 321] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 11/05/2020] [Indexed: 12/25/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels <500 µm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions.This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH.It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.
Collapse
Affiliation(s)
- Marion Delcroix
- Clinical Dept of Respiratory Diseases, Pulmonary Hypertension Center, UZ Leuven, Leuven, Belgium .,BREATHE, Dept CHROMETA, KU Leuven, Leuven, Belgium.,Co-chair
| | - Adam Torbicki
- Dept of Pulmonary Circulation, Thrombo-embolic Diseases and Cardiology, Center of Postgraduate Medical Education, ECZ-Otwock, Otwock, Poland.,Section editors
| | - Deepa Gopalan
- Dept of Radiology, Imperial College Hospitals NHS Trusts, London, UK.,Section editors
| | - Olivier Sitbon
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Frederikus A Klok
- Dept of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands.,Section editors
| | - Irene Lang
- Medical University of Vienna, Vienna, Austria.,Section editors
| | - David Jenkins
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Nick H Kim
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, CA, USA.,Section editors
| | - Marc Humbert
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Xavier Jais
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Section editors
| | - Anton Vonk Noordegraaf
- Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands.,Section editors
| | - Joanna Pepke-Zaba
- Royal Papworth Hospital, Cambridge University Hospital, Cambridge, UK.,Section editors
| | - Philippe Brénot
- Marie Lannelongue Hospital, Paris-South University, Le Plessis Robinson, France
| | - Peter Dorfmuller
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Elie Fadel
- Hannover Medical School, Hannover, Germany
| | - Hossein-Ardeschir Ghofrani
- University of Giessen and Marburg Lung Center, German Center of Lung Research (DZL), Giessen, Germany.,Dept of Medicine, Imperial College London, London, UK.,Dept of Pneumology, Kerckhoff-Clinic Bad Nauheim, Bad Nauheim, Germany
| | | | - Pavel Jansa
- 2nd Department of Medicine, Dept of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Michael Madani
- Sulpizio Cardiovascular Centre, University of California, San Diego, CA, USA
| | - Hiromi Matsubara
- National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Takeshi Ogo
- National Cerebral and Cardiovascular Centre, Osaka, Japan
| | - Ekkehard Grünig
- Thoraxklinik Heidelberg at Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea D'Armini
- Unit of Cardiac Surgery, Intrathoracic Transplantation and Pulmonary Hypertension, University of Pavia School of Medicine, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | | | - Bernhard Meyer
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | | | | | - Eckhard Mayer
- Dept of Thoracic Surgery, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany.,Equal contribution.,Co-chair
| | - Gérald Simonneau
- Université Paris-Saclay; Inserm UMR_S 999, Service de Pneumologie, Hôpital Bicêtre (AP-HP), Le Kremlin-Bicêtre, France.,Equal contribution.,Co-chair
| |
Collapse
|
|
13
|
Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Cardiovasc Interv Ther 2021; 37:60-65. [PMID: 33928528 DOI: 10.1007/s12928-021-00775-6] [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: 04/02/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is caused by chronic stenosis or obstruction of the pulmonary arteries due to thromboembolism. Although previous studies have shown untreated CTEPH has a poor prognosis, the establishment of gold-standard therapies including pulmonary endarterectomy, balloon pulmonary angioplasty (BPA), and medical therapy has improved hemodynamics and right ventricular function, leading to good long-term survival. BPA is an important therapy for patients with inoperable CTEPH, although the procedure is currently limited to specific institutions and operators. This review discusses the development of the rapidly evolving field of CTEPH that includes improvements in imaging modalities and advances in surgical and interventional techniques.
Collapse
|
|
14
|
Kligerman S, Hsiao A. Optimizing the diagnosis and assessment of chronic thromboembolic pulmonary hypertension with advancing imaging modalities. Pulm Circ 2021; 11:20458940211007375. [PMID: 34104420 PMCID: PMC8150458 DOI: 10.1177/20458940211007375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/10/2020] [Indexed: 02/05/2023] Open
Abstract
Imaging is key to nearly all aspects of chronic thromboembolic pulmonary hypertension including management for screening, assessing eligibility for pulmonary endarterectomy, and post-operative follow-up. While ventilation/perfusion scintigraphy, the gold standard technique for chronic thromboembolic pulmonary hypertension screening, can have excellent sensitivity, it can be confounded by other etiologies of pulmonary malperfusion, and does not provide structural information to guide operability assessment. Conventional computed tomography pulmonary angiography has high specificity, though findings of chronic thromboembolic pulmonary hypertension can be visually subtle and unrecognized. In addition, computed tomography pulmonary angiography can provide morphologic information to aid in pre-operative workup and assessment of other structural abnormalities. Advances in computed tomography imaging techniques, including dual-energy computed tomography and spectral-detector computed tomography, allow for improved sensitivity and specificity in detecting chronic thromboembolic pulmonary hypertension, comparable to that of ventilation/perfusion scans. Furthermore, these advanced computed tomography techniques, compared with conventional computed tomography, provide additional physiologic data from perfused blood volume maps and improved resolution to better visualize distal chronic thromboembolic pulmonary hypertension, an important consideration for balloon pulmonary angioplasty for inoperable patients. Electrocardiogram-synchronized techniques in electrocardiogram-gated computed tomography can also show further information regarding right ventricular function and structure. While the standard of care in the workup of chronic thromboembolic pulmonary hypertension includes a ventilation/perfusion scan, computed tomography pulmonary angiography, direct catheter angiography, echocardiogram, and coronary angiogram, in the future an electrocardiogram-gated dual-energy computed tomography angiography scan may enable a "one-stop" imaging study to guide diagnosis, operability assessment, and treatment decisions with less radiation exposure and cost than traditional chronic thromboembolic pulmonary hypertension imaging modalities.
Collapse
Affiliation(s)
- Seth Kligerman
- Cardiothoracic Imaging, University of California San Diego, La Jolla, CA, USA
| | - Albert Hsiao
- Cardiothoracic Imaging, University of California San Diego, La Jolla, CA, USA
| |
Collapse
|
|
15
|
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2510] [Impact Index Per Article: 627.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
|
16
|
Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
Collapse
Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
| |
Collapse
|
|
17
|
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) and chronic thromboembolic pulmonary vascular disease (CTED) are rare manifestations of venous thromboembolism. Presumably, CTEPH and CTED are variants of the same pathophysiological mechanism. CTEPH and CTED can be near-cured by pulmonary endarterectomy, balloon pulmonary angioplasty, and medical treatment with Riociguat or subcutaneous treprostinil, which are the approved drugs.
Collapse
|
|
18
|
Lange TJ, Borst M, Ewert R, Halank M, Klose H, Leuchte H, Meyer FJ, Seyfarth HJ, Skowasch D, Wilkens H, Held M. [Current Aspects of Definition and Diagnosis of Pulmonary Hypertension]. Pneumologie 2020; 74:847-863. [PMID: 32663892 DOI: 10.1055/a-1199-1548] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
At the 6th World Symposium on Pulmonary Hypertension (WSPH), which took place from February 27 until March 1, 2018 in Nice, scientific progress over the past 5 years in the field of pulmonary hypertension (PH) was presented by 13 working groups. The results of the discussion were published as proceedings towards the end of 2018. One of the major changes suggested by the WSPH was the lowering of the diagnostic threshold for PH from ≥ 25 to > 20 mmHg mean pulmonary arterial pressure, measured by right heart catheterization at rest. In addition, the pulmonary vascular resistance was introduced into the definition of PH, which underlines the importance of cardiac output determination at the diagnostic right heart catheterization.In this article, we discuss the rationale and possible consequences of a changed PH definition in the context of the current literature. Further, we provide a current overview on non-invasive and invasive methods for diagnosis, differential diagnosis, and prognosis of PH, including exercise tests.
Collapse
Affiliation(s)
- T J Lange
- Uniklinik Regensburg, Klinik für Innere Medizin II, Bereich Pneumologie, Regensburg
| | - M Borst
- Medizinische Klinik I, Caritas-Krankenhaus, Bad Mergentheim
| | - R Ewert
- Pneumologie, Uniklinik Greifswald, Greifwald
| | - M Halank
- Universitätsklinikum Carl Gustav Carus, Medizinische Klinik 1, Bereich Pneumologie, Dresden
| | - H Klose
- Universitätsklinikum Hamburg-Eppendorf, Abteilung für Pneumologie, Hamburg
| | - H Leuchte
- Klinik der Barmherzigen Schwestern, Krankenhaus Neuwittelsbach, Lehrkrankenhaus der LMU München, München
| | - F J Meyer
- Lungenzentrum München (Bogenhausen-Harlaching), München Klinik gGmbH, München
| | - H-J Seyfarth
- Bereich Pneumologie, Universitätsklinikum Leipzig, Leipzig
| | - D Skowasch
- Universitätsklinikum Bonn, Medizinische Klinik II, Sektion Pneumologie, Bonn
| | - H Wilkens
- Klinik für Innere Medizin V, Universitätsklinikum des Saarlandes, Homburg
| | - M Held
- Medizinische Klinik mit Schwerpunkt Pneumologie und Beatmungsmedizin, Klinikum Würzburg Mitte, Standort Missioklinik, Würzburg
| |
Collapse
|
|
19
|
Jin Q, Zhao ZH, Luo Q, Zhao Q, Yan L, Zhang Y, Li X, Yang T, Zeng QX, Xiong CM, Liu ZH. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: State of the art. World J Clin Cases 2020; 8:2679-2702. [PMID: 32742980 PMCID: PMC7360712 DOI: 10.12998/wjcc.v8.i13.2679] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/10/2020] [Indexed: 02/05/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a complex chronic disease in which pulmonary artery stenosis or obstruction caused by organized thrombus can lead to increased pulmonary artery pressure and pulmonary vascular resistance, ultimately triggering progressive right heart failure and death. Currently, its exact mechanism is not fully understood. Pulmonary endarterectomy (PEA) has immediate effects with low perioperative mortality and satisfactory prognosis in experienced expert centers for CTEPH patients with proximal lesions. Nevertheless, 37% of patients are deemed unsuitable for PEA surgery due to comorbidities and other factors, and nearly half of the operated patients have residual or recurrent pulmonary hypertension. Riociguat is the only approved drug for CTEPH, although its effect is limited. Balloon pulmonary angioplasty (BPA) is a promising alternative treatment for patients with CTEPH. After more than 30 years of development and refinements, emerging evidence has confirmed its role in patients with inoperable CTEPH or residual/recurrent pulmonary hypertension, with acceptable complications and comparable long-term prognosis to PEA. This review summarizes the pathophysiology of CTEPH, BPA history and development, therapeutic principles, indications and contraindications, interventional procedures, imaging modalities, efficacy and prognosis, complications and management, bridging and hybrid therapies, ongoing clinical trials and future prospects.
Collapse
Affiliation(s)
- Qi Jin
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hui Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qin Luo
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qing Zhao
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lu Yan
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Yi Zhang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xin Li
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Tao Yang
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Qi-Xian Zeng
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Chang-Ming Xiong
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhi-Hong Liu
- State Key Laboratory of Cardiovascular Disease, Center for Pulmonary Vascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| |
Collapse
|
|
20
|
Lin JL, Chen HM, Lin FC, Li JY, Xie CX, Guo WL, Huang XF, Hong C. Application of DynaCT angiographic reconstruction in balloon pulmonary angioplasty. Eur Radiol 2020; 30:6950-6957. [PMID: 32621239 DOI: 10.1007/s00330-020-07028-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 05/02/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the feasibility and accuracy of balloon pulmonary angioplasty (BPA) using DynaCT angiographic reconstruction guidance. METHODS Thirty-four BPAs (23 CTEPH patients) targeting 175 pulmonary arteries were included. Eleven BPAs (2D group) were guided by DSA two-dimensional angiography. Another twenty-three BPAs (3D group) were guided using DynaCT angiographic reconstruction. The volume rendering (VR) method was used to obtain a three-dimensional image of the blood vessels. This image was used as a reference to continue BPA treatment under the guidance of vascular three-dimensional reconstruction technology. Procedure durations and radiation exposure data were compared between the two groups using Mann-Whitney U test. RESULTS Using the DynaCT angiographic reconstruction technique, more target vessels were treated in a single BPA procedure (5.83 ± 2.33 vs 3.73 ± 1.10 vessels per BPA, p = 0.008) in a shorter operation time (3.58 ± 0.61 vs 4.49 ± 0.91 h, p = 0.002). Overall, the dose area product (DAP) was significantly higher for the 2D group than for the 3D group (13,901.82 ± 5549.69 vs 4682.82 ± 1950.64, p < 0.001). The use of the DynaCT angiographic reconstruction technique to guide BPA required a lower dose of contrast agent (225.22 ± 48.70 vs 292.73 ± 76.82 mL, p = 0.013) and less radiation exposure. CONCLUSIONS The use of DynaCT angiographic reconstruction guidance in patients undergoing BPA is feasible and accurate. Images of DynaCT angiographic reconstruction may be beneficial for optimizing the operative process in BPA with reduced radiation exposure. KEY POINTS • BPA guidance by DynaCT angiographic reconstruction is feasible and accurate. • DynaCT angiographic reconstruction may be beneficial for optimizing the operative process. • DynaCT angiographic reconstruction can reduce patient radiation dose due to multi-times of BPA sessions.
Collapse
Affiliation(s)
- Jie-Long Lin
- Department of Radiology, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510010, China
| | - Hai-Ming Chen
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510010, China
| | - Feng-Cheng Lin
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510010, China
| | - Jie-Ying Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510010, China
| | - Cheng-Xin Xie
- Department of Pulmonary and Critical Care Medicine, The First People's Hospital of Kashgar Prefecture, Kashgar, Xinjiang, 844000, China
| | - Wen-Liang Guo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510010, China
| | - Xiu-Fen Huang
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, 510010, China
| | - Cheng Hong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Road, Guangzhou, 510010, China.
| |
Collapse
|
|
21
|
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Áinle FN, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Respir J 2019; 54:13993003.01647-2019. [DOI: 10.1183/13993003.01647-2019] [Citation(s) in RCA: 509] [Impact Index Per Article: 84.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
|
22
|
Huang WC, Hsu CH, Sung SH, Ho WJ, Chu CY, Chang CP, Chiu YW, Wu CH, Chang WT, Lin L, Lin SL, Cheng CC, Wu YJ, Wu SH, Hsieh TY, Hsu HH, Fu M, Dai ZK, Kuo PH, Hwang JJ, Cheng SM. 2018 TSOC guideline focused update on diagnosis and treatment of pulmonary arterial hypertension. J Formos Med Assoc 2019; 118:1584-1609. [PMID: 30926248 DOI: 10.1016/j.jfma.2018.12.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/18/2018] [Accepted: 12/14/2018] [Indexed: 01/04/2023] Open
Abstract
Pulmonary arterial hypertension (PAH) is characterized as a progressive and sustained increase in pulmonary vascular resistance, which may induce right ventricular failure. In 2014, the Working Group on Pulmonary Hypertension of the Taiwan Society of Cardiology (TSOC) conducted a review of data and developed a guideline for the management of PAH.4 In recent years, several advancements in diagnosis and treatment of PAH has occurred. Therefore, the Working Group on Pulmonary Hypertension of TSOC decided to come up with a focused update that addresses clinically important advances in PAH diagnosis and treatment. This 2018 focused update deals with: (1) the role of echocardiography in PAH; (2) new diagnostic algorithm for the evaluation of PAH; (3) comprehensive prognostic evaluation and risk assessment; (4) treatment goals and follow-up strategy; (5) updated PAH targeted therapy; (6) combination therapy and goal-orientated therapy; (7) updated treatment for PAH associated with congenital heart disease; (8) updated treatment for PAH associated with connective tissue disease; and (9) updated treatment for chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
- Wei-Chun Huang
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan
| | - Chih-Hsin Hsu
- Department of Internal Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Shih-Hsien Sung
- School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Wan-Jing Ho
- Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chun-Yuan Chu
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Chih-Ping Chang
- Division of Cardiology, China Medical University Hospital, Taichung, Taiwan
| | - Yu-Wei Chiu
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Chun-Hsien Wu
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Ting Chang
- Division of Cardiovascular Medicine, Chi-Mei Medical Center, Tainan City, Taiwan
| | - Lin Lin
- Cardiovascular Center, National Taiwan University Hospital, Hsinchu Branch, Hsinchu, Taiwan
| | - Shoa-Lin Lin
- Department of Internal Medicine, Yuan's General Hospital, Kaohsiung, Taiwan
| | - Chin-Chang Cheng
- Department of Critical Care Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; School of Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Physical Therapy, Fooyin University, Kaohsiung, Taiwan; Pulmonary Hypertension Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Shu-Hao Wu
- Pulmonary Hypertension Interventional Medicine, Cardiovascular Center, Mackay Memorial Hospital, Taipei City, Taiwan
| | - Tsu-Yi Hsieh
- Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Morgan Fu
- Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Zen-Kong Dai
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Ping-Hung Kuo
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Cardiovascular Division, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; National Taiwan University Hospital Yunlin Branch, Douliu City, Taiwan.
| | - Shu-Meng Cheng
- Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
| | | |
Collapse
|
|
23
|
Nakanishi N, Fukai K, Tsubata H, Ogata T, Zen K, Nakamura T, Yamano T, Shiraishi H, Shirayama T, Matoba S. Angioscopic Evaluation During Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension. Heart Lung Circ 2018; 28:655-659. [PMID: 30224170 DOI: 10.1016/j.hlc.2018.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 04/20/2018] [Accepted: 08/17/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disorder with a poor prognosis. Recently, balloon pulmonary angioplasty (BPA) has been reported to be an effective treatment for inoperable patients with CTEPH. However, this catheter-based treatment has potentially life-threatening vascular complications. To improve the efficacy and safety of BPA, we assessed the morphological evaluation of organised thrombus and the vascular injury by BPA procedure. METHODS In this study, we assessed the morphology of organised thrombi and the vascular injury observed by angioscopy during BPA in 28 lesions from nine CTEPH patients. RESULTS Angioscopy visualised various forms of organised thrombi such as 'Mesh', 'Slit', 'Flap' and 'Mass' and allowed for a detailed evaluation of organised thrombus that was difficult to do by conventional contrast angiography. In addition, after balloon dilation for BPA, angioscopy revealed a haemorrhage due to a vessel wall injury caused by wiring and/or ballooning. CONCLUSIONS Assessment of organised thrombus and vascular injury by angioscopy might contribute to improving the treatment of the patients with CTEPH.
Collapse
Affiliation(s)
- Naohiko Nakanishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan.
| | - Kuniyoshi Fukai
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hideo Tsubata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takehiro Ogata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Nakamura
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tetsuhiro Yamano
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirokazu Shiraishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takeshi Shirayama
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
|
24
|
Ogawa A, Matsubara H. After the Dawn - Balloon Pulmonary Angioplasty for Patients With Chronic Thromboembolic Pulmonary Hypertension. Circ J 2018; 82:1222-1230. [PMID: 29669971 DOI: 10.1253/circj.cj-18-0258] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
In the past 5 years, balloon pulmonary angioplasty (BPA) for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are deemed inoperable has undergone significant refinement. As a result, the procedure is now used worldwide and has become a promising therapeutic option for those patients. However, pulmonary endarterectomy remains the gold standard treatment for patients with CTEPH because the techniques and strategies for BPA are not yet unified. The best therapeutic option for each patient should be determined based on discussion among a multidisciplinary team of experts. For BPA to become an established treatment for CTEPH, further data are needed. This review summarizes the techniques and strategies of BPA at present and discusses the future development of the procedure.
Collapse
Affiliation(s)
- Aiko Ogawa
- Department of Clinical Science, National Hospital Organization Okayama Medical Center
| | - Hiromi Matsubara
- Department of Clinical Science, National Hospital Organization Okayama Medical Center
| |
Collapse
|
|
25
|
Madani M, Ogo T, Simonneau G. The changing landscape of chronic thromboembolic pulmonary hypertension management. Eur Respir Rev 2017; 26:26/146/170105. [PMID: 29263176 PMCID: PMC9488650 DOI: 10.1183/16000617.0105-2017] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/25/2017] [Indexed: 01/09/2023] Open
Abstract
For patients with chronic thromboembolic pulmonary hypertension (CTEPH), the current standard of care involves surgical removal of fibro-thrombotic obstructions by pulmonary endarterectomy. While this approach has excellent outcomes, significant proportions of patients are not eligible for surgery or suffer from persistent/recurrent pulmonary hypertension after the procedure. The availability of balloon pulmonary angioplasty and the approval of the first medical therapy for use in CTEPH have significantly improved the outlook for patients ineligible for pulmonary endarterectomy. In this comprehensive review, we discuss the latest developments in the rapidly evolving field of CTEPH. These include improvements in imaging modalities and advances in surgical and interventional techniques, which have broadened the range of patients who may benefit from such procedures. The efficacy and safety of targeted medical therapies in CTEPH patients are also discussed, particularly the encouraging data from the recent MERIT-1 trial, which demonstrated the beneficial impact of using macitentan to treat patients with inoperable CTEPH, including those on background therapy. As the treatment options for CTEPH improve, hybrid management involving more than one intervention in the same patient may become a viable option in the near future. Management of CTEPH is evolving rapidly, leading to improved patient outcomeshttp://ow.ly/rHrt30gUQWX
Collapse
|
|
26
|
Ogawa A, Satoh T, Fukuda T, Sugimura K, Fukumoto Y, Emoto N, Yamada N, Yao A, Ando M, Ogino H, Tanabe N, Tsujino I, Hanaoka M, Minatoya K, Ito H, Matsubara H. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. Circ Cardiovasc Qual Outcomes 2017; 10:CIRCOUTCOMES.117.004029. [DOI: 10.1161/circoutcomes.117.004029] [Citation(s) in RCA: 159] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 09/27/2017] [Indexed: 12/21/2022]
Abstract
Background—
Balloon pulmonary angioplasty (BPA) is an alternative therapy for patients with chronic thromboembolic pulmonary hypertension who are ineligible for pulmonary endarterectomy—the standard therapy. Currently, most reported results of BPA are from relatively small cohorts treated at single centers. The present study evaluated the safety and efficacy of BPA for chronic thromboembolic pulmonary hypertension based on a multicenter registry.
Methods and Results—
A total of 308 patients (62 men and 246 women; mean age, 61 years) underwent 1408 procedures at 7 institutions in Japan. Data were retrospectively reviewed to evaluate clinical outcome and complications. Hemodynamics were significantly improved in 249 patients in whom BPA was terminated, most often because of improvement in mean pulmonary arterial pressure or symptomatic improvement after 1154 procedures. In 196 patients who underwent follow-up right heart catheterization, improvement of hemodynamic parameters was maintained. Mean pulmonary arterial pressure decreased from 43.2±11.0 to 24.3±6.4 mm Hg after final BPA and 22.5±5.4 mm Hg at follow-up, with significant reduction of concomitant use of pulmonary hypertension-targeted therapy and oxygen supplementation. Complications occurred in 511 (36.3%), including pulmonary injury (17.8%), hemoptysis (14.0%), and pulmonary artery perforation (2.9%). Twelve patients (3.9%) died during follow-up, including 8 patients who died within 30 days after BPA. The leading causes of death were right heart failure, multiorgan failure, and sepsis. Overall survival was 96.8% (95% confidence interval, 93.7%–98.4%) at 1 and 2 years and 94.5% (95% confidence interval, 89.3%–97.3%) at 3 years, respectively, after the initial BPA procedure for all 308 patients.
Conclusions—
This multicenter registry suggested improved hemodynamic results after BPA. Complication rates were high, but overall survival was comparable with pulmonary endarterectomy. BPA may be an important therapeutic option in patients with chronic thromboembolic pulmonary hypertension.
Collapse
Affiliation(s)
- Aiko Ogawa
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Toru Satoh
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Tetsuya Fukuda
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Koichiro Sugimura
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Yoshihiro Fukumoto
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Noriaki Emoto
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Norikazu Yamada
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Atsushi Yao
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Motomi Ando
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Hitoshi Ogino
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Nobuhiro Tanabe
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Ichizo Tsujino
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Masayuki Hanaoka
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Kenji Minatoya
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Hiroshi Ito
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| | - Hiromi Matsubara
- From the Department of Clinical Science, National Hospital Organization Okayama Medical Center, Japan (A.O., H.M.); Division of Cardiology, Department of Medicine, Kyorin University School of Medicine, Tokyo, Japan (T.S.); Department of Radiology (T.F.) and Department of Cardiovascular Surgery (K.M.), National Cerebral and Cardiovascular Center, Suita, Japan; Department of Cardiovascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan (K.S.); Division of Cardiovascular
| |
Collapse
|
|
27
|
Lang I, Meyer BC, Ogo T, Matsubara H, Kurzyna M, Ghofrani HA, Mayer E, Brenot P. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017; 26:26/143/160119. [PMID: 28356406 PMCID: PMC9489135 DOI: 10.1183/16000617.0119-2016] [Citation(s) in RCA: 176] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 02/22/2017] [Indexed: 01/26/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to result from incomplete resolution of pulmonary thromboemboli that undergo organisation into fibrous tissue within pulmonary arterial branches, filling pulmonary arterial lumina with collagenous obstructions. The treatment of choice is pulmonary endarterectomy (PEA) in CTEPH centres, which has low post-operative mortality and good long-term survival. For patients ineligible for PEA or who have recurrent or persistent pulmonary hypertension after surgery, medical treatment with riociguat is beneficial. In addition, percutaneous balloon pulmonary angioplasty (BPA) is an emerging option, and promises haemodynamic and functional benefits for inoperable patients. In contrast to conventional angioplasty, BPA with undersized balloons over guide wires exclusively breaks intraluminal webs and bands, without dissecting medial vessel layers, and repeat sessions are generally required. Observational studies report that BPA improves haemodynamics, symptoms and functional capacity in patients with CTEPH, but controlled trials with long-term follow-up are needed. Complications include haemoptysis, wire injury, vessel dissection, vessel rupture, reperfusion pulmonary oedema, pulmonary parenchymal bleeding and haemorrhagic pleural effusions. This review summarises the available evidence for BPA, patient selection, recent technical refinements and periprocedural imaging, and discusses the potential future role of BPA in the management of CTEPH. Balloon pulmonary angioplasty is an emerging percutaneous vascular intervention for non-operable CTEPHhttp://ow.ly/tIN3309hys3
Collapse
Affiliation(s)
- Irene Lang
- Dept of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Bernhard C Meyer
- Dept of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Takeshi Ogo
- Division of Pulmonary Circulation, Dept of Advanced Medicine for Pulmonary Hypertension, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiromi Matsubara
- Dept of Clinical Science, National Hospital Organization, Okayama Medical Centre, Okayama, Japan
| | - Marcin Kurzyna
- Dept of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland
| | - Hossein-Ardeschir Ghofrani
- Universities of Giessen and Marburg Lung Center, Giessen, Germany, Member of the German Center for Lung Research (DZL).,Dept of Medicine, Imperial College London, London, UK
| | - Eckhard Mayer
- Kerckhoff Heart and Lung Center, Bad Nauheim, Germany
| | | |
Collapse
|
|
28
|
Gopalan D, Delcroix M, Held M. Diagnosis of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2017; 26:26/143/160108. [PMID: 28298387 DOI: 10.1183/16000617.0108-2016] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 01/10/2017] [Indexed: 12/19/2022] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the only potentially curable form of pulmonary hypertension. Rapid and accurate diagnosis is pivotal for successful treatment. Clinical signs and symptoms can be nonspecific and risk factors such as history of venous thromboembolism may not always be present. Echocardiography is the recommended first diagnostic step. Cardiopulmonary exercise testing is a complementary tool that can help to identify patients with milder abnormalities and chronic thromboembolic disease, triggering the need for further investigation. Ventilation/perfusion (V'/Q') scintigraphy is the imaging methodology of choice to exclude CTEPH. Single photon emission computed tomography V'/Q' is gaining popularity over planar imaging. Assessment of pulmonary haemodynamics by right heart catheterisation is mandatory, although there is increasing interest in noninvasive haemodynamic evaluation. Despite the status of digital subtraction angiography as the gold standard, techniques such as computed tomography (CT) and magnetic resonance imaging are increasingly used for characterising the pulmonary vasculature and assessment of operability. Promising new tools include dual-energy CT, combination of rotational angiography and cone beam CT, and positron emission tomography. These innovative procedures not only minimise misdiagnosis, but also provide additional vascular information relevant to treatment planning. Further research is needed to determine how these modalities will fit into the diagnostic algorithm for CTEPH.
Collapse
Affiliation(s)
- Deepa Gopalan
- Imperial College Hospitals, London, UK.,Cambridge University Hospital, Cambridge, UK
| | | | - Matthias Held
- Medical Mission Hospital, Dept of Internal Medicine, Center for Pulmonary Hypertension and Pulmonary Vascular Disease, Academic Teaching Hospital, Julius-Maximilian University of Würzburg, Würzburg, Germany
| |
Collapse
|
|
29
|
Efficacy and safety of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension guided by cone-beam computed tomography and electrocardiogram-gated area detector computed tomography. Eur J Radiol 2016; 89:270-276. [PMID: 28034568 DOI: 10.1016/j.ejrad.2016.12.013] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/16/2016] [Accepted: 12/15/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is a disease characterized by chronic obstructive thrombus and pulmonary hypertension. Balloon pulmonary angioplasty (BPA), an emerging alternative catheter-based treatment for inoperable patients with CTEPH, has not yet been standardised, especially for lesion assessment in distal pulmonary arteries. Recent advancement in computed tomography enables distal CTEPH lesions to be visualized. METHODS We retrospectively studied 80 consecutive patients with inoperable CTEPH who received BPA guided by cone-beam computed tomography (CT) (CBCT) or electrocardiogram (ECG)-gated area detector CT (ADCT) for target lesion assessment. We collected clinical and hemodynamic data, including procedural complications, before BPA and at 3 months and 1year after BPA. RESULTS Three hundred eight-five BPA sessions (4.8 sessions/patient) were performed for the lesions of subsegmental arteries (1155 lesions), segmental arteries (738 lesions), and lobar arteries (4 lesions) identified by CBCT or ECG-gated ADCT. Significant improvements in the symptoms, 6-min walk distance, brain natriuretic peptide level, exercise capacity, and haemodynamics were observed 3 months and 1year after BPA. No cases of death or cardiogenic shock with a low rate of severe wire perforation (0.3%) and severe reperfusion oedema (0.3%) were observed. CONCLUSIONS BPA guided by CBCT or ECG-gated ADCT is effective and remarkably safe in patients with CTEPH . These new advanced CT techniques may be useful in pre-BPA target lesion assessment.
Collapse
|