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ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) is a known sequela of acute pulmonary embolic disease and yet remains underdiagnosed. Although nonsurgical options for patients with CTEPH have become increasingly available, including pulmonary artery hypertensive medical therapy, surgical endarterectomy provides the most appropriate intervention as a potential cure for this debilitating disorder. This article summarizes the most recent outcomes of pulmonary endarterectomy at a single institution over the past 12 years, with emphasis on the surgical approach to segmental-level chronic thromboembolic disease.
More than 2,700 pulmonary endarterectomy operations have been performed at the University of California, San Diego Medical Center. Because of recent changes in the patient population and in surgical results, 1,500 patients with symptomatic chronic thromboembolic disease who underwent pulmonary endarterectomy between March 1999 and December 2010 were analyzed. The outcomes for the more recent 500 patients, compared with the previous 1,000 were studied.
In-hospital mortality for the cohort of 1,000 patients (group 1) was 5.2% compared with 2.2% for the last 500 operations (group 2) (p < 0.01). There was no mortality in the last 260 consecutive patients undergoing isolated pulmonary endarterectomy. More patients presented with segmental type III disease in the more recent 500 patients (21.4% versus 13.1%; p < 0.001). Between the 2 patient groups, there was a comparable decline in pulmonary vascular resistance (PVR) (group 1: 861.2 ± 446.2 to 94.8 ± 204.2 dynes/sec/cm(-5); group 2: 719.0 ± 383.2 to 253.4 ± 148.6 dynes/sec/cm(-5)) and mean pulmonary artery (PA) pressures (group 1: 46.1 ± 11.4 to 28.7 ± 10.1 mm Hg; group 2: 45.5 ± 11.6 to 26.0 ± 8.4 mm Hg) after endarterectomy.
Despite a patient population with more distal disease, results continue to improve. Pulmonary endarterectomy for patients with CTEPH results in significant pulmonary hemodynamic improvement, with favorable outcomes achievable even in patients with distal segmental-level chronic thromboembolic disease.
The Annals of thoracic surgery 05/2012; 94(1):97-103; discussion 103. · 3.74 Impact Factor
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ABSTRACT: Pulmonary hypertension as a result of chronic thromboembolic disease (CTEPH) is potentially curable with pulmonary endarterectomy surgery. Consequently, correctly diagnosing patients with this type of pulmonary hypertension and evaluating these patients with the goal of establishing their candidacy for surgical intervention is of utmost importance. And as advancements in surgical techniques have allowed successful resection of segmental-level chronic thromboembolic disease, the number of CTEPH patients that are deemed suitable surgical candidates has expanded, making it even more important that the evaluation be conducted with greater precision. This article will review a diagnostic approach to patients with suspected chronic thromboembolic disease with an emphasis on the criteria considered in selecting patients for pulmonary endarterectomy surgery.
Pulmonary circulation. 04/2012; 2(2):155-62.
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Kim M Kerr, William R Auger,
James J Marsh,
Gehan Devendra,
Roger G Spragg,
Nick H Kim,
Richard N Channick,
Stuart W Jamieson,
Michael M Madani,
Gerard R Manecke,
David M Roth,
Gordon P Shragg,
Peter F Fedullo
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ABSTRACT: We sought to determine the efficacy and safety of perioperative treatment with methylprednisolone on the development of lung injury after pulmonary thromboendarterectomy.
This was a randomized, prospective, double-blind, placebo-controlled study of 98 adult patients with chronic thromboembolic pulmonary hypertension who were undergoing pulmonary thromboendarterectomy at a single institution. The patients received either placebo (n = 47) or methylprednisolone (n = 51) (30 mg/kg in the cardiopulmonary bypass prime, 500 mg IV bolus following the final circulatory arrest, and 250 mg IV bolus 36 h after surgery). The primary end point was the presence of lung injury as determined by two independent, blinded physicians using prospectively defined criteria. The secondary end points included ventilator-free, ICU-free, and hospital-free days and selected levels of cytokines in the blood and in BAL fluid.
The incidence of lung injury was similar in both treatment groups (45% placebo, 41% steroid; P = .72). There were no statistical differences in the secondary clinical end points between treatment groups. Treatment with methylprednisolone, compared with placebo, was associated with a statistically significant reduction in plasma IL-6 and IL-8, a significant increase in plasma IL-10, and a significant reduction in postoperative IL-1ra and IL-6, but not IL-8 in BAL fluid obtained 1 day after surgery.
Perioperative methylprednisolone does not reduce the incidence of lung injury following pulmonary thromboendarterectomy surgery despite having an antiinflammatory effect on plasma and lavage cytokine levels.
Chest 08/2011; 141(1):27-35. · 5.25 Impact Factor
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ABSTRACT: Chronic thromboembolic pulmonary hypertension is a rare form of pulmonary hypertension that can lead to progressive right heart failure and death. Pulmonary thromboendarterectomy surgery is the treatment of choice resulting in significant improvements in functional status, cardiopulmonary hemodynamics, and survival. This study reports the largest case series of pediatric patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy surgery at one institution.
The University of California, San Diego, chronic thromboembolic pulmonary hypertension database identified patients 18 years or younger at the time of pulmonary thromboendarterectomy surgery (n = 17). Medical charts were reviewed for hemodynamics, thromboembolic risk factors, and postoperative outcomes.
Pulmonary thromboendarterectomy surgery in pediatric patients resulted in improved functional status and significantly improved cardiopulmonary hemodynamics: mean arterial pressure decreased from 45.5 mm Hg ± 20.7 to 27.3 ± 13.0 mm Hg (P = .00073), pulmonary vascular resistance decreased from 929 ± dynes · s · cm(-5) to 299 ± 307 dynes · s · cm(-5) (P = .0012), and cardiac output improved from 3.8 ± 1.1 L/min to 5.6 ± 1.6 L/min (P = .0061). There were no deaths during surgery or 30 days after surgery, and long-term survival (5+ years) was achieved in 87.5%. As compared to adults with chronic thromboembolic pulmonary hypertension, there was a higher rate of rethrombosis in pediatric patients (38% vs 1%-4%).
This study demonstrates that pulmonary thromboendarterectomy surgery in pediatric patients with chronic thromboembolic pulmonary hypertension is well tolerated with improved postoperative hemodynamics, functional status, minimal postoperative complications, and low perioperative mortality, similar to that reported for adults with chronic thromboembolic pulmonary hypertension, with the notable exception being a higher rate of rethrombosis in pediatric patients.
The Journal of thoracic and cardiovascular surgery 03/2011; 141(3):624-30. · 3.41 Impact Factor
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Journal of cardiothoracic and vascular anesthesia 02/2011; 25(1):183-91. · 1.06 Impact Factor
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ABSTRACT: Over the past 4 decades, chronic thromboembolic pulmonary hypertension has evolved from an autopsy curiosity to a potentially correctable form of pulmonary hypertension. Advances in surgical techniques along with the introduction of pulmonary hypertension disease-modifying therapies provide a therapeutic option for the majority of patients afflicted with the disease. Approximately 5,000 thromboendarterectomy procedures have now been performed worldwide with mortality rates reported by established programs experienced in the management of this disease process falling to a range of 4 to 7%. A mortality rate of 1.3% has been reported in patients at low risk based on their preoperative hemodynamic profile. After a successful pulmonary thromboendarterectomy, substantial improvement and often normalization can be achieved in right ventricular function, gas exchange, exercise capacity, and quality of life. For patients not candidates for thromboendarterectomy, or for those with persistent post-thromboendarterectomy pulmonary hypertension, disease-modifying medical therapies have been demonstrated to stabilize and improve pulmonary hemodynamics, albeit not to the same extent as primary thromboendarterectomy. The current review focuses on the diagnostic approach to chronic thromboembolic pulmonary hypertension and the available surgical and medical therapeutic options. Additional research is necessary to more accurately predict postoperative hemodynamic outcome and to define the optimal therapeutic approach, especially in patients with involvement of the distal vasculature.
American Journal of Respiratory and Critical Care Medicine 02/2011; 183(12):1605-13. · 11.08 Impact Factor
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ABSTRACT: Chronic thromboembolic pulmonary hypertension is one of the few forms of pulmonary hypertension that is surgically curable. It is likely underdiagnosed and must be considered in every patient presenting with pulmonary hypertension to avoid missing the opportunity to cure these patients. This article discusses the epidemiology, risk factors, natural history, diagnosis, and preoperative evaluation of patients with this disorder. Also covered are putative mechanisms for the conversion of acute emboli into fibrosed thrombembolic residua. Mechanical obstruction of the central pulmonary vasculature is rarely the sole cause of the pulmonary hypertension, and a discussion of the small vessel arteriopathy present in these patients is offered. Technical aspects of pulmonary endartectomy and the data supporting its role are discussed, as are the limited data on pulmonary arterial hypertension specific medical therapies for patients deemed noncandidates for the operation.
Clinics in chest medicine 12/2010; 31(4):741-58. · 2.51 Impact Factor
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ABSTRACT: The pulmonary hypertension (PH) and right heart dysfunction that results from chronic thromboembolic involvement of the pulmonary vascular bed is potentially curable with surgical endarterectomy. Over the past several decades, growing clinical experience has brought about increased recognition of this treatable form of PH. Moreover, advances in cardiothoracic surgical techniques have given an increasing number of patients with chronic thromboembolic PH (CTEPH) a surgical remedy with decreasing perioperative morbidity and mortality risks. The availability of pulmonary hypertensive-specific medical therapy for CTEPH patients with surgically inaccessible disease also has been a positive therapeutic advance over the past several years. However, despite this progress, chronic thromboembolic disease as a sequela of acute pulmonary emboli continues to be underappreciated. Furthermore, even if CTEPH has been appropriately diagnosed, misinterpretation of diagnostic information may lead to the inappropriate exclusion of patients from surgical consideration. This may result in the prescription of pulmonary hypertensive medical therapy in CTEPH patients with potentially surgically correctable disease. This difficulty arises from a lack of objective criteria as to what constitutes surgical chronic thromboembolic disease, which primarily is a result of the variability in surgical experience in specialty centers in the United States. Consequently, clinicians must be wary about using pulmonary hypertensive medications in CTEPH patients. Before prescription, it is important to exclude patients from surgical consideration by consulting a specialized center with expertise in this discipline.
Current Treatment Options in Cardiovascular Medicine 04/2010; 12(2):131-41.
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ABSTRACT: Echocardiographic evaluation of left ventricular (LV) strain and strain rate (SR) by 2D speckle tracking may be useful tools to assess chronic thromboembolic pulmonary hypertension (CTEPH) severity as well as response to successful pulmonary thromboendarterectomy (PTE).
We evaluated 30 patients with CTEPH before and after PTE using 2D speckle tracking measurements of LV radial and circumferential strain and SR in the short axis, and correlated the data with right heart catheterization (RHC).
PTE resulted in a decrease in mean PA pressure (44 ± 15 to 29 ± 9 mmHg), decrease in PVR (950 ± 550 to 31 ± 160 [dyne-sec]/cm⁵), and an increase in cardiac output (3.9 ± 1.0 to 5.0 ± 1.0 L/min, p < 0.001 for all). Circumferential and posterior wall radial strain changed by -11% and +15% respectively (p < 0.001 for both). Circumferential SR and posterior wall radial SR changed by -7% and 6% after PTE. While the increase in posterior wall SR with PTE reached statistical significance (p = 0.04) circumferential SR did not (p = 0.07). In addition, septal radial strain and SR did not change significantly after PTE (p = 0.1 and 0.8 respectively). Linear regression analyses of circumferential and posterior wall radial strain and SR revealed little correlation between strain/SR measurements and PVR, mean PA pressure, or cardiac output. However, change in circumferential strain and change in posterior wall radial strain correlated moderately well with changes in PVR, mean PA pressure and cardiac output (r = 0.69, 0.76, and 0.51 for circumferential strain [p < 0.001 for all] and r = 0.7, 0.7, 0.45 for posterior wall radial strain [p = 0.001, 0.001, and 0.02, respectively]).
LV circumferential and posterior wall radial strain change after relief of pulmonary arterial obstruction in patients with CTEPH, and these improvements occur rapidly. These changes in LV strain may reflect effects from improved LV diastolic filling, and may be useful non-invasive markers of successful PTE.
Cardiovascular Ultrasound 01/2010; 8:43. · 1.26 Impact Factor
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ABSTRACT: The last 4 decades have witnessed dramatic changes in the treatment of patients with pulmonary hypertension. And with the advances in cardiothoracic surgical techniques, selected patients with chronic thromboembolic pulmonary hypertension (CTEPH) are afforded a surgical remedy for their disease. In the vast majority of these patients, surgical endarterectomy of chronic thromboemboli from the pulmonary vascular bed effectively treats even severe pulmonary hypertension, and as a result, the debilitating symptoms of right heart dysfunction. This article reviews the natural history of chronic thromboembolic disease and outline a suggested diagnostic approach to determine whether a patient with chronic thromboembolic disease might be an appropriate surgical candidate. Pulmonary thromboendarterectomy surgery, and the growing information on the use of pharmacotherapy in inoperable CTEPH, are also reviewed.
Seminars in Respiratory and Critical Care Medicine 09/2009; 30(4):471-83. · 2.43 Impact Factor
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ABSTRACT: The currently recommended treatment for chronic thromboembolic pulmonary hypertension is pulmonary thromboendarterectomy (PTE). No convincing evidence for the use of pulmonary hypertensive medical therapy (PHT) exists in operable candidates. We sought to determine the prevalence of the use of PHT on referral for PTE and the effects on pre-PTE hemodynamics and post-PTE outcomes/hemodynamics.
We performed a retrospective analysis of chronic thromboembolic pulmonary hypertension patients referred for PTE during 2005-2007. The prevalence of PHT was determined for all patients referred to our institution. Hemodynamic and outcomes analysis involved only those undergoing PTE. Data included baseline demographics, PHT medication(s), dosage, duration of therapy, and time to referral. Hemodynamic data were acquired from the time of diagnosis, the time of referral visit, and after PTE. Outcomes included intensive care unit, hospital, and ventilator days; bleeding and infection rates; incidence of reperfusion lung injury; and in-hospital mortality. The control group (n=244) was compared with the PHT group (n=111); subgroups included monotherapy with bosentan, sildenafil, or epoprostenol and combination therapy. The prevalence of PHT significantly increased from 19.9% in 2005 to 37% in 2007. There was minimal benefit of treatment with PHT on pre-PTE mean pulmonary artery pressure, but its use was associated with a significant delay in time to referral for PTE. Both groups experienced significant improvements in hemodynamic parameters after PTE. The 2 groups did not differ significantly in any post-PTE outcome. Similar results were obtained for each subgroup.
Our results suggest that PHT use has minimal effect on pre-PTE hemodynamics and no effect on post-PTE outcomes/hemodynamics.
Circulation 09/2009; 120(13):1248-54. · 14.74 Impact Factor
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ABSTRACT: Pulmonary vascular remodeling occurs in patients with chronic thromboembolic pulmonary hypertension (CTEPH). One factor contributing to this vascular wall thickening is the proliferation of pulmonary artery smooth muscle cells (PASMC). Store-operated Ca(2+) entry (SOCE) and cytosolic free Ca(2+) concentration ([Ca(2+)](cyt)) in PASMC are known to be important in cell proliferation and vascular remodeling in pulmonary hypertension. Rapamycin is widely known for its antiproliferative effects in injured coronary arteries. Although several reports have suggested favorable effects of rapamycin in animal models of pulmonary hypertension, no reports have been published to date in human tissues. Here we report that rapamycin has an inhibitory effect on SOCE and an antiproliferative effect on PASMC derived from endarterectomized tissues of CTEPH patients. Cells were isolated from endarterectomized tissues obtained from patients undergoing pulmonary thromboendarterectomy (PTE). Immunohistochemical analysis indicated high deposition of platelet-derived growth factor (PDGF) in tissue sections from PTE tissues and increased PDGF receptor expression. PDGF transiently phosphorylated Akt, mammalian target of rapamycin (mTOR), and p70S6 kinase in CTEPH cells from CTEPH patients. Acute treatment (30 min) with rapamycin (10 nM) slightly increased cyclopiazonic acid (10 microM)-induced Ca(2+) mobilization and significantly reduced SOCE. Chronic treatment (24 h) with rapamycin reduced Ca(2+) mobilization and markedly inhibited SOCE. The inhibitory effects of rapamycin on SOCE were less prominent in control cells. Rapamycin also significantly reduced PDGF-stimulated cell proliferation. In conclusion, the data from this study indicate the importance of the mTOR pathway in the development of pulmonary vascular remodeling in CTEPH and suggest a potential therapeutic benefit of rapamycin (or inhibition of mTOR) in these patients.
AJP Lung Cellular and Molecular Physiology 08/2009; 297(4):L666-76. · 3.66 Impact Factor
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Weijuan Yao,
Amy L Firth,
Richard S Sacks,
Aiko Ogawa, William R Auger,
Peter F Fedullo,
Michael M Madani,
Grace Y Lin,
Naohide Sakakibara,
Patricia A Thistlethwaite,
Stuart W Jamieson,
Lewis J Rubin,
Jason X-J Yuan
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ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by a fibrotic thrombus persisting and obliterating the lumen of pulmonary arteries; its pathogenesis remains poorly defined. This study investigates a potential contribution for progenitor cell types in the development of vascular obliteration and remodeling in CTEPH patients. Endarterectomized tissue from patients undergoing pulmonary thromboendarterectomy was collected and examined for the structure and cellular composition. Our data show an organized fibrin network structure in unresolved thromboemboli and intimal remodeling in vascular wall tissues, characterized by smooth muscle alpha-actin (SM-alphaA)-positive cell proliferation in proximal regions (adjacent to thromboemboli) and neoangiogenesis/recanalization in distal regions (downstream from thromboemboli). Cells that are positively stained with CD34 and fetal liver kinase-1 (Flk-1) (CD34(+)Flk-1(+)) were identified in both the proximal and distal vascular tissues; a subpopulation of CD34(+)Flk-1(+)CD133(+) cells were further identified by immunostaining. Triple-positive cells are indicative of a population of putative endothelial progenitor cells or potential colony-forming units of endothelial cells. In addition, inflammatory cells (CD45(+)) and collagen-secreting cells (procollagen-1(+)) were detected in the proximal vascular wall. Some of the CD34(+) cells in CTEPH cells isolated from proximal regions were also positive for SM-alphaA. Our data indicate that putative progenitor cell types are present in the neointima of occluded vessels of CTEPH patients. It is possible that the microenvironment provided by thromboemboli may promote these putative progenitor cells to differentiate and enhance intimal remodeling.
AJP Lung Cellular and Molecular Physiology 04/2009; 296(6):L870-8. · 3.66 Impact Factor
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ABSTRACT: We evaluated the utility of tissue Doppler-derived right ventricular (RV) Tei (or myocardial performance) index in patients with chronic thromboembolic pulmonary hypertension (CTEPH) before and after pulmonary thromboendarterectomy (PTE) and assessed correlations with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR), and cardiac output (CO).
The assessment of RV function is limited with 2-dimensional echocardiography. The RV Tei index, an indicator of RV myocardial performance, is derived by Doppler measurements and is unaffected by RV geometry. The use of tissue Doppler imaging (at the lateral tricuspid annulus) for RV Tei index calculation is simple and eliminates the need for pulsed-wave Doppler recordings of both RV inflow and outflow.
Ninety-three patients with CTEPH were prospectively studied along with 13 control patients. Right ventricular tissue Doppler imaging and right heart catheterization were performed before and after PTE. Right ventricular Tei index was compared with values of mPAP, PVR, and CO with the use of linear regression.
Right ventricular Tei index was 0.52 +/- 0.19 in patients with CTEPH and 0.27 +/- 0.09 in control patients (p < 0.0001). After PTE, RV Tei index decreased to 0.33 +/- 0.10 (p < 0.0001). Pulmonary vascular resistance correlated well with RV Tei index before (r = 0.78, p < 0.0001) and after (r = 0.67, p < 0.0001) surgery. Also, the absolute change in Tei index in each patient after PTE correlated well with the concomitant change in PVR (r = 0.75, p < 0.0001). RV Tei index did not correlate as well with mPAP (pre-operatively: r = 0.55, p < 0.0001; post-operatively: r = 0.26, p = 0.03) or CO (pre-operatively: r = 0.57, p < 0.0001; post-operatively: r = 0.43, p < 0.0001).
These results demonstrate a correlation between RV Tei index and right heart hemodynamics (particularly PVR) in CTEPH. Because PVR is difficult to estimate noninvasively -- and yet correlates with disease severity -- the RV Tei index may be a valuable noninvasive parameter for monitoring disease severity in CTEPH and outcome after PTE.
JACC. Cardiovascular imaging 03/2009; 2(2):143-9. · 14.29 Impact Factor
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Marin H Kollef,
Bekele Afessa,
Antonio Anzueto,
Christopher Veremakis,
Kim M Kerr,
Benjamin D Margolis,
Donald E Craven,
Pamela R Roberts,
Alejandro C Arroliga,
Rolf D Hubmayr,
Marcos I Restrepo, William R Auger,
Regina Schinner
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ABSTRACT: Ventilator-associated pneumonia (VAP) causes substantial morbidity. A silver-coated endotracheal tube has been designed to reduce VAP incidence by preventing bacterial colonization and biofilm formation.
To determine whether a silver-coated endotracheal tube would reduce the incidence of microbiologically confirmed VAP.
Prospective, randomized, single-blind, controlled study conducted in 54 centers in North America. A total of 9417 adult patients (> or = 18 years) were screened between 2002 and 2006. A total of 2003 patients expected to require mechanical ventilation for 24 hours or longer were randomized.
Patients were assigned to undergo intubation with 1 of 2 high-volume, low-pressure endotracheal tubes, similar except for a silver coating on the experimental tube.
Primary outcome was VAP incidence based on quantitative bronchoalveolar lavage fluid culture with 10(4) colony-forming units/mL or greater in patients intubated for 24 hours or longer. Other outcomes were VAP incidence in all intubated patients, time to VAP onset, length of intubation and duration of intensive care unit and hospital stay, mortality, and adverse events.
Among patients intubated for 24 hours or longer, rates of microbiologically confirmed VAP were 4.8% (37/766 patients; 95% confidence interval [CI], 3.4%-6.6%) in the group receiving the silver-coated tube and 7.5% (56/743; 95% CI, 5.7%-9.7%) (P = .03) in the group receiving the uncoated tube (all intubated patients, 3.8% [37/968; 95% CI, 2.7%-5.2%] and 5.8% [56/964; 95% CI, 4.4%-7.5%] [P = .04]), with a relative risk reduction of 35.9% (95% CI, 3.6%-69.0%; all intubated patients, 34.2% [95% CI, 1.2%-67.9%]). The silver-coated endotracheal tube was associated with delayed occurrence of VAP (P = .005). No statistically significant between-group differences were observed in durations of intubation, intensive care unit stay, and hospital stay; mortality; and frequency and severity of adverse events.
Patients receiving a silver-coated endotracheal tube had a statistically significant reduction in the incidence of VAP and delayed time to VAP occurrence compared with those receiving a similar, uncoated tube.
clinicaltrials.gov Identifier: NCT00148642.
JAMA The Journal of the American Medical Association 08/2008; 300(7):805-13. · 30.03 Impact Factor
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ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) is an important form of pulmonary hypertension to detect because prompt
treatment can lead to a surgical cure. The true incidence is unknown, but it is estimated to occur in 1% to 3% of patients
following acute thromboembolism. Detection may be difficult, because symptoms are nonspecific and other diagnoses are often
made before that of CTEPH is entertained. Routinely screening all pulmonary hypertension patients with a ventilation–perfusion
scan will detect most, however. Candidates for thromboendarterectomy are evaluated using right heart catheterization, computerized
tomographic angiography, and pulmonary angiography, seeking those with proximal obstructions that can be removed surgically.
Patients who are not candidates for thromboendarterectomy because of comorbidities, very high pulmonary vascular resistances.
or mainly distal disease may still receive medical therapy or be considered for lung transplantation.
05/2008: pages 199-230;
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ABSTRACT: Pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) are important hemodynamic parameters in patients with advanced cardiopulmonary disease. We undertook this study to determine whether Doppler tissue imaging of the tricuspid annulus could be used to assess PAP and PVR noninvasively.
We studied 50 consecutive patients with suspected chronic thromboembolic pulmonary hypertension referred to our center for evaluation. We performed preoperative transthoracic echocardiography with Doppler tissue imaging of the tricuspid annulus. All patients then underwent cardiac catheterization with invasive determination of cardiac output, PAP, and PVR.
The systolic velocity of the tricuspid annulus (tS(m)) had an inverse relationship with catheterization-derived mean PAP, with a correlation coefficient of -0.493 (P = .0003). The inverse correlation of tS(m) with catheterization-derived PVR was more striking, with a correlation coefficient of -0.710 (P < .0001). Based on the data, we derived the following logarithmic regression equation: PVR = 3698 - 1227 x ln(tS(m)).
Doppler tissue imaging of the lateral tricuspid annulus is a useful clinical tool that can provide a noninvasive estimate of PVR in patients with chronic thromboembolic pulmonary hypertension. In this population, decreasing values of tS(m) predicted progressively higher measurements of PVR.
Journal of the American Society of Echocardiography: official publication of the American Society of Echocardiography 10/2007; 20(10):1167-71. · 2.98 Impact Factor
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ABSTRACT: The description of organized thrombus in major pulmonary arteries can be found in autopsy reports dating back to the late nineteenth and early twentieth centuries. Not until the 1950s was the antemortem diagnosis and clinical syndrome of chronic thrombotic obstruction of the major pulmonary arteries better characterized. The first surgical attempt to remove the adherent thrombus from the vessel wall occurred in 1958. This operation provided the conceptual foundation for the distinction between acute and chronic thromboembolic disease of the pulmonary vascular bed, and established that an endarterectomy, and not an embolectomy, would be necessary if a surgical remedy for this disease was to be successful.
Clinics in Chest Medicine 04/2007; 28(1):255-69, x. · 3.28 Impact Factor
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ABSTRACT: The purpose of this study was to investigate the cause of abnormal left ventricular (LV) Doppler diastolic filling characteristics in chronic thromboembolic pulmonary hypertension (CTEPH).
In CTEPH, LV diastolic function often appears abnormal. It is unclear whether this "impaired relaxation" (E<A) filling pattern is caused by septal hypertrophy, right ventricular (RV) enlargement and LV chamber distortion, or low LV preload and underfilling.
We studied 61 patients with an E<A transmitral pattern and CTEPH who underwent pulmonary thromboendarterectomy (PTE). We compared the results of pre- and postoperative transthoracic echocardiography and right heart catheterization measurements.
After PTE, mitral E velocity increased (from 54 +/- 16 cm/s to 81 +/- 20 cm/s, p < 0.001), whereas A velocity decreased (77 +/- 22 cm/s to 71 +/- 20 cm/s, p < 0.001). E/A ratio normalized (0.72 +/- 0.16 cm/s to 1.22 +/- 0.40 cm/s, p < 0.001). Pulmonary venous systolic and diastolic velocities both increased (57 +/- 13 cm/s to 68 +/- 16 cm/s and 39 +/- 15 cm/s to 70 +/- 21 cm/s, respectively, p < 0.001 for both). Diastolic velocity of the septal mitral annulus (E(m)) did not change after PTE (8.0 +/- 3.1 cm/s to 8.1 +/- 2.0 cm/s, p = ns), whereas the velocity of the lateral mitral annulus increased (9.3 +/- 3.2 cm/s to 11.8 +/- 3.1 cm/s, p < 0.001). Mean pulmonary capillary wedge pressure increased from 9.3 +/- 3.2 mm Hg to 10.6 +/- 3.8 mm Hg (p = 0.035). Despite these marked changes in LV inflow, M-mode measurements of LV septal and posterior wall thickness were normal before PTE and did not change after surgery (septal: 10 +/- 2 mm vs. 10 +/- 1 mm; posterior: 10 +/- 2 mm vs. 10 +/- 1 mm; p = NS for both comparisons).
The results of this study strongly suggest that the impaired relaxation pattern observed in patients with CTEPH is not solely the result of geometric effects of RV enlargement and LV chamber distortion but is caused in large part by low LV preload and relative underfilling.
Journal of the American College of Cardiology 03/2007; 49(12):1334-9. · 14.16 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate the accuracy and precision of a novel algorithm that evaluates cardiac output by using arterial pressure waveform characteristics.
Prospective, observational study comparing the cardiac output values of intermittent thermodilution, continuous thermodilution, and continuous arterial pressure wave assessment.
The intensive care unit in a tertiary care university hospital.
Fifty postoperative cardiac surgical patients, within the first 12 hours after surgery. Interventions: All patients received a pulmonary artery catheter (PAC) and at least 1 systemic arterial pressure catheter. The data from the arterial catheter were processed by using a new arterial pressure cardiac output (APCO) algorithm. The data from the PAC (continuous and intermittent assessments) were collected for comparison with the APCO. Measurements: Two hundred ninety-five cardiac output measurements using intermittent thermodilution (ICO), continuous thermodilution (CCO), and arterial pressure-based output (APCO) were obtained during various times during the first 12 postoperative hours. The measurements of each method at each time point were compared by using Bland-Altman analysis.
The mean cardiac output ranged from 2.77 to 9.60 L/min. APCO, compared with ICO, revealed a bias of 0.55 L/min and precision of 0.98 L/min. APCO, compared with CCO, revealed a bias of 0.06 L/min and precision of 1.06 L/min. The APCO agreement between femoral and radial arterial catheters was close; the bias was -0.15 L/min, and the precision was 0.56 L/min.
This novel arterial pressure cardiac output algorithm provides cardiac output assessments that agree satisfactorily for clinical purposes with intermittent and continuous thermodilution techniques in postoperative cardiac surgical patients. Further study is required for other patient populations and clinical situations.
Journal of Cardiothoracic and Vascular Anesthesia 03/2007; 21(1):3-7. · 1.64 Impact Factor
