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ABSTRACT: Coagulopathy is common after cardiopulmonary bypass (CPB), and platelet dysfunction is frequently considered to be a major contributor to excessive bleeding. Exposure to hypothermia may exacerbate the platelet function defect. We assessed platelet function during and after deep hypothermia with multiple electrode aggregometry (Multiplate(®); Verum Diagnostica GmbH, Munich, Germany).
Twenty adult patients undergoing pulmonary endarterectomy for chronic pulmonary hypertension were cooled on CPB to 20°C and deep hypothermic arrest was used to facilitate surgery. We analyzed platelet aggregation in whole blood samples at 12 measuring points during and after the procedure. Platelet aggregation was stimulated via the thrombin receptor (TRAPtest) at the patient's actual body temperature (AUC-CT) and after rewarming the samples to 37°C (AUC-37). In addition, we tested samples at 2 time points after 2 minutes of in vitro incubation with 20 μg protamine (0.067 μg/μL). Results are expressed as area under the aggregation curve (AUC).
Cooling resulted in a marked decrease of platelet aggregation to a minimum AUC-CT of 20.5 (95% confidence interval [CI] 8.9-32.1) at 20°C body temperature. AUC-CT was significantly different from baseline (92.8, 95% CI 82.5-103.1) for temperatures of ≤28°C (P < 0.001), whereas the change in AUC-37 only became significant at the lowest body temperature (59.4, 95% CI 41.3-77.4). After rewarming to 36°C, AUC-CT and AUC-37 had recovered to 67.6 (95% CI 53.9-81.3) and 71.7 (95% CI 52.5-90.8), respectively. The mean AUC-CT was significantly lower than the mean AUC-37 from cooling at 28°C to warming at 24°C inclusive, and the relationship with temperature during cooling was significantly different between AUC-CT and AUC-37 (regression coefficients 4.7 [95% CI 4.2-5.2] vs 1.3 [95% CI 0.7-1.9]; P < 0.0001). After administration of protamine, mean aggregation decreased significantly for both measurements by 38.2 (95% CI -27.9 to -48.5; P < 0.001) and 44.5 (95% CI -58.5 to -30.5; P < 0.001), respectively. Similarly, adding protamine in vitro resulted in a decrease of mean aggregation by 35.1 (95% CI -71.0 to 0.8; P = 0.055) when measured after administration of heparin, and 56.5 (95% CI -94.5 to -18.5; P = 0.005) at the end of CPB.
Platelet aggregation, assessed by multiple electrode aggregometry (Multiplate), was severely affected during deep, whole-body hypothermia. This effect was partially reversible after rewarming, and was distinct from a general decline of platelet aggregation during CPB. Protamine also caused a significant decrease in platelet aggregation in vivo and in vitro.
Anesthesia and analgesia 03/2013; 116(3):533-40. · 3.08 Impact Factor
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ABSTRACT: OBJECTIVES: Raised pulmonary artery pressure (PAP), trans-pulmonary gradient (TPG) and pulmonary vascular resistance (PVR) are risk factors for poor outcomes after heart transplant in patients with secondary pulmonary hypertension (PH) and may contraindicate transplant. Unloading of the left ventricle with an implantable left ventricular assist device (LVAD) may reverse these pulmonary vascular changes. We studied the effect of implanting centrifugal LVADs in a cohort of patients with secondary PH as a bridge to candidacy. METHODS: Pulmonary haemodynamics on patients implanted with centrifugal LVADs at a single unit between May 2005 and December 2010 were retrospectively reviewed. RESULTS: Twenty-nine patients were implanted with centrifugal LVADs (eight HeartWare ventricular assist device (HVAD), HeartWare International, USA and 21 VentrAssist, Ventracor Ltd., Australia). Seventeen were ineligible for transplant by virtue of high TPG/PVR. All the patients were optimized with inotrope/balloon pump followed by LVAD insertion. Four required temporary right VAD support. Thirty-day mortality post-LVAD was 3.4% (1 of 29) with a 1-year survival of 85.7% (24 of 28). Thirteen patients have been transplanted to date: 30-day mortality was 7.7% (1 of 13) and 1-year survival was 91% (10 of 11). Baseline and post-VAD pulmonary haemodynamics were significantly improved: systolic PAP (mmHg), mean PAP, TPG (mmHg) of 57 ± 9.5, 42 ± 4.4 and 14 ± 3.9 reduced to 32 ± 7.5, 18 ± 5.5 and 9 ± 3.3, respectively. PVR reduced from 5 ± 1.5 to 2.1 ± 0.5 Wood units (P < 0.05). CONCLUSIONS: In selected heart failure patients with secondary PH, use of centrifugal LVAD results in significant reductions in PAP, TPG and PVR, which are observed within 1 month, reaching a nadir by 3 months. Such patients bridged to candidacy have post-transplant survival comparable with those having a heart transplant as primary treatment.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 01/2013; · 2.40 Impact Factor
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ABSTRACT: The treatment of choice for symptomatic chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy
(Annals of Thoracic Surgery 76:1457-1462, 2003). This is the only proven treatment to offer significant symptomatic and prognostic
benefit. The operation, as performed today, was developed by Jamieson at the University of California in San Diego (UCSD),
and this unit is the world leader having now completed over 2,000 procedures. CTEPH has been reviewed extensively recently
(Circulation 113(16):2011-2020, 2006), and a detailed explanation of the technical aspects of surgery is available as part
of a series of seminars on CTEPH (Seminars in Thoracic Cardiovascular Surgery 18:243-249, 2006). The most complete account
of surgery for this condition and the development of the service at UCSD is by Stuart Jamieson himself in a detailed specialist
monograph (Current Problems in Surgery 37(3):165-252, 2000).
British journal of hospital medicine (London, England: 2005) 01/2013; 74(1):31-5. · 0.19 Impact Factor
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ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) is the only cause of pulmonary hypertension for which there is a potential cure, which is in the form of pulmonary endarterectomy. There is a strong link between pulmonary embolism (PE) and the development of CTEPH. Although CTEPH was initially believed to be a rare complication, this belief has been reconsidered following several studies suggesting that up to 8.8% of patients develop CTEPH within the 2 years after PE. However, considering the incidence of PE, there is a significant discrepancy in the number of patients who are diagnosed, referred, and treated for CTEPH. Potential reasons for this include its often vague clinical presentation, the variable association of CTEPH with PE, and discrepancies when interpreting imaging studies. Underdiagnosis of CTEPH is preventing patients from accessing potentially curative therapy. Increased awareness about this condition is an important initial step to improving diagnostic rates and treatment.
Hospital practice (1995). 08/2012; 40(3):71-9.
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ABSTRACT: Advanced age is not a barrier to cardiac surgery, with reports demonstrating excellent outcomes, but the effect of age on more complex surgery has not been studied. We assessed the outcomes of pulmonary endarterectomy (PEA) surgery in patients aged >70.
A retrospective review of consecutive patients who underwent PEA between January 2006 and March 2011 at a national referral centre. The total cohort was dichotomized according to age on the day of surgery, either below or above 70 years. Outcomes were in-hospital mortality, overall survival and the length of ICU and hospital stays.
Four hundred and eleven patients underwent PEA during the 5-year period. The mean age was 56.9 years (range, 17-84 years). The in-hospital mortality was 14 of 308 (4.6%) for patients <70 years compared with 8 of 103 (7.8%) for patients ≥70 years (P = 0.21). The overall survival at 1, 2 and 3 years was 91.4, 89.9 and 87.7% in the <70-year old group and 85.9, 84.1 and 84.1% in the >70-year old group (log-rank test, P = 0.07), respectively. The length of ICU and in-hospital stays was longer in the >70-year old group, by 1 and 2 days, respectively (P = 0.005 and 0.001).
PEA surgery in patients ≥70 years is safe and carries a comparable risk of early mortality in younger patients, but there is an increase in resource use due to longer ICU and hospital stays. Advanced age should be taken into consideration when assessing suitability for PEA, but age per se should not be a contraindication to surgery.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 06/2012; 41(6):e154-60. · 2.40 Impact Factor
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ABSTRACT: Pulmonary endarterectomy (PEA) is the definitive surgical treatment for chronic thromboembolic pulmonary hypertension, with excellent short- and long-term results. PEA following previous coronary artery bypass graft surgery carries a risk of damage to patent grafts, as well as the risk of inadequate myocardial protection, especially when a patent pedicled internal thoracic artery graft is present. We report a technique where PEA may be safely and successfully accomplished ensuring, adequate clearance of bilateral pulmonary thromboembolic disease via a right pulmonary arteriotomy, avoiding the patent bypass grafts overlying the pulmonary trunk, while ensuring adequate myocardial protection.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2012; 42(1):175-7. · 2.40 Impact Factor
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ABSTRACT: Untreated severe chronic thromboembolic pulmonary hypertension has a poor prognosis ending with right heart decompensation and multiorgan failure. This case report demonstrates that it is possible to intervene in the terminal stages of chronic thromboembolic pulmonary hypertension and bridge patients to surgery and recovery using various forms of extracorporeal membrane oxygenation support.
The Annals of thoracic surgery 11/2011; 92(5):e101-3. · 3.74 Impact Factor
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Moronke A Noah,
Giles J Peek,
Simon J Finney,
Mark J Griffiths,
David A Harrison,
Richard Grieve,
M Zia Sadique,
Jasjeet S Sekhon,
Daniel F McAuley,
Richard K Firmin, [......],
Susanna Price,
Alain Vuylsteke, David P Jenkins,
David W Noble,
Roxanna Bloomfield,
Timothy S Walsh,
Gavin D Perkins,
David Menon,
Bruce L Taylor,
Kathryn M Rowan
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ABSTRACT: Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients with severe acute respiratory distress syndrome (ARDS), but its role has remained controversial. ECMO was used to treat patients with ARDS during the 2009 influenza A(H1N1) pandemic.
To compare the hospital mortality of patients with H1N1-related ARDS referred, accepted, and transferred for ECMO with matched patients who were not referred for ECMO.
A cohort study in which ECMO-referred patients were defined as all patients with H1N1-related ARDS who were referred, accepted, and transferred to 1 of the 4 adult ECMO centers in the United Kingdom during the H1N1 pandemic in winter 2009-2010. The ECMO-referred patients and the non-ECMO-referred patients were matched using data from a concurrent, longitudinal cohort study (Swine Flu Triage study) of critically ill patients with suspected or confirmed H1N1. Detailed demographic, physiological, and comorbidity data were used in 3 different matching techniques (individual matching, propensity score matching, and GenMatch matching).
Survival to hospital discharge analyzed according to the intention-to-treat principle.
Of 80 ECMO-referred patients, 69 received ECMO (86.3%) and 22 died (27.5%) prior to discharge from the hospital. From a pool of 1756 patients, there were 59 matched pairs of ECMO-referred patients and non-ECMO-referred patients identified using individual matching, 75 matched pairs identified using propensity score matching, and 75 matched pairs identified using GenMatch matching. The hospital mortality rate was 23.7% for ECMO-referred patients vs 52.5% for non-ECMO-referred patients (relative risk [RR], 0.45 [95% CI, 0.26-0.79]; P = .006) when individual matching was used; 24.0% vs 46.7%, respectively (RR, 0.51 [95% CI, 0.31-0.81]; P = .008) when propensity score matching was used; and 24.0% vs 50.7%, respectively (RR, 0.47 [95% CI, 0.31-0.72]; P = .001) when GenMatch matching was used. The results were robust to sensitivity analyses, including amending the inclusion criteria and restricting the location where the non-ECMO-referred patients were treated.
For patients with H1N1-related ARDS, referral and transfer to an ECMO center was associated with lower hospital mortality compared with matched non-ECMO-referred patients.
JAMA The Journal of the American Medical Association 10/2011; 306(15):1659-68. · 30.03 Impact Factor
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Guy Hagan,
Deepa Gopalan,
Colin Church,
Doris Rassl,
Chetan Mukhtyar,
Trevor Wistow,
Chim Lang,
Pasupathy Sivasothy,
Susan Stewart,
David Jayne,
Karen Sheares,
Steven Tsui, David P Jenkins,
Joanna Pepke-Zaba
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ABSTRACT: Isolated pulmonary artery involvement by large vessel vasculitis is rare. This case report describes two patients with large vessel pulmonary vasculitis initially thought to have chronic thromboembolic pulmonary hypertension who had their diagnosis revised following pulmonary endarterectomy surgery. Advances in imaging techniques such as positron emission tomography and magnetic resonance imaging have permitted complementary radiological methods of diagnosis and follow up of large vessel disease and these are discussed in conjunction with the immunosuppressive and operative management of these patients.
Pulmonary circulation. 07/2011; 1(3):425-9.
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ABSTRACT: This study assessed the utility of dual-energy pulmonary CT angiography (CTA) for noninvasive assessment of regional pulmonary perfusion in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Regional perfusion abnormalities were correlated with hemodynamic parameters and structural abnormalities on pulmonary CTA.
Twenty patients with CTEPH (11 men and nine women; mean age, 61.5 years) underwent pulmonary CTA with a dual-energy technique. Right heart catheterization data were available in 15 cases. Scan parameters were as follows: tube A, 140 kV (75 mA); tube B, 80 kV (300 mA); gantry rotation, 500 milliseconds; pitch, 0.5; and collimation, 14 × 1.2 mm. An iodine map was generated via three-material-decomposition and was scored for extent of hypoperfusion. Correlation was made with mosaic attenuation pattern, extent of vascular obstruction, and right heart hemodynamics. Iodine attenuation values were analyzed within completely occluded, partially occluded, and disease-free lobes.
A strong correlation existed between dual-energy CT-derived perfusion and mosaic attenuation pattern when both lobar (r > 0.6; n = 20; p < 0.006) and whole-lung scores were assessed (r = 0.77; n = 20; p < 0.001). There was no statistically significant correlation between dual-energy CT perfusion and vascular obstructive index, mean pulmonary artery pressure, or pulmonary vascular resistance (p > 0.08). Of 42 completely occluded lobes, 27 (64%) had demonstrable residual perfusion (mismatching), suggesting that blood supply was maintained via systemic collaterals.
Dual-energy CT can offer a "one-stop" assessment of anatomy and perfusion in CTEPH. The additional information provided by dual-energy CT could have a future role in helping guide patient selection for thromboendarterectomy surgery.
American Journal of Roentgenology 03/2011; 196(3):524-32. · 2.78 Impact Factor
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ABSTRACT: Pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension. In many patients hemodynamics are normalized early after surgical intervention. However, the effect of residual pulmonary hypertension on postoperative clinical status and survival is unknown.
Data were collected prospectively on all patients who underwent pulmonary endarterectomy in a continuous national series between 1997 and December 2007. Postoperatively, patients underwent scheduled reinvestigation, including functional testing and right heart catheterization, at 3 months after the operation. They were divided into 2 groups based on mean pulmonary artery pressure: group 1, less than 30 mm Hg; group 2, 30 mm Hg or greater.
Three hundred fourteen patients underwent pulmonary endarterectomy, survived to hospital discharge, and completed the 3-month follow-up period. At 3 months after pulmonary endarterectomy, there was a significant reduction in mean pulmonary artery pressure for the whole cohort (48±12 to 26±10 mm Hg, P<.001). However, 31% of the patients had residual pulmonary hypertension. Group 1 patients enjoyed significantly better exercise capacity and improved symptoms compared with group 2 patients. In addition, there were significantly fewer patients receiving targeted medical therapy in group 1 versus group 2 (0% vs 25%, P<.001). Conditional survival after discharge from the hospital for the whole cohort was 90.0% at 5 years and was not different between groups (90.3% for group 1 vs 89.9% for group 2, P=.36).
For patients undergoing pulmonary endarterectomy, survival after hospital discharge is excellent. Residual pulmonary hypertension significantly compromised symptom status and functional capacity but did not appear to adversely affect medium-term survival. The effect of targeted medical therapy in patients with residual pulmonary hypertension after pulmonary endarterectomy needs to be evaluated further.
The Journal of thoracic and cardiovascular surgery 02/2011; 141(2):383-7. · 3.41 Impact Factor
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Marius Berman,
Jayan Parameshwar, David P Jenkins,
Kumud Dhital,
Clive Lewis,
Kirsty Dempster,
Paul Lincoln,
Catherine Sudarshan,
Stephen R Large,
John Dunning,
Steven S L Tsui
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ABSTRACT: The Thoratec (Thoratec Corp, Pleasanton, Calif) implantable ventricular assist device (IVAD) can be used for univentricular or biventricular support. The objective of this study is to review the 5-year experience of bridging patients to heart transplantation with this device in a single center. Surgical aspects, including hybrid pump pocket, double tunneling of driveline, and optimal cannulae placement, are discussed.
This is a retrospective review of 24 patients treated between January 2002 and December 2007. Nineteen patients (79.1%) received a single implantable ventricular assist device as left ventricular assist devices, and 5 patients (21.9%) received 2 implantable ventricular assist devices as biventricular assist devices. The devices were implanted in pre-peritoneal/posterior rectus hybrid pump pockets. The driveline was passed through a 2-stage double-tunnel to exit onto the lateral chest wall. Patients were anticoagulated with Warfarin aiming for an international normalized ratio of 2.0 to 3.0.
Twenty male and 4 female patients with a mean age of 39.8 years (17-57 years) and a body surface area of 1.87 m(2) (1.63-2.2 m(2)) were supported for a total of 2308 patient-days. Mean duration of support was 96 days (10-301 days). The cause of heart failure was dilated cardiomyopathy in 18 patients and ischemic cardiomyopathy in 6 patients. Preoperatively, 23 patients were receiving inotropes, 12 patients required intra-aortic balloon pump support, 5 patients were intubated and mechanically ventilated, and 3 patients required continuous venovenous hemofiltration for renal support. Eleven patients (45.8%) were discharged with ventricular assist device support (1015 home patient-days). Complications observed were a) neurologic: stroke in 3 patients, transient ischemic attacks in 4 patients; and b) infection: driveline infection in 3 patients and pump pocket infection in 1 patient. There was no mechanical device failure. Support to transplantation was achieved in 17 patients (70.8%): 3 of 5 biventricular assist devices (60%) and 14 of 19 left ventricular assist devices (73.7%).
The Thoratec IVAD is a versatile and reliable ventricular assist device. It can provide univentricular or biventricular support for bridging patients to heart transplantation with acceptable complication rates. The portable Thoratec TLC-II console facilitated discharge while patients waited for a suitable donor heart.
The Journal of thoracic and cardiovascular surgery 10/2009; 139(2):466-73. · 3.41 Impact Factor
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The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 11/2008; 27(10):1188-9. · 3.54 Impact Factor
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Marius Berman,
Steven Tsui,
Alain Vuylsteke,
Andrew Snell,
Simon Colah,
Ray Latimer,
Roger Hall,
Joseph E Arrowsmith,
John Kneeshaw,
Andrew A Klein, David P Jenkins
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ABSTRACT: Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension. However, some patients develop severe cardiorespiratory compromise soon after separating from cardiopulmonary bypass, either from early reperfusion pulmonary edema or right ventricular failure secondary to residual pulmonary hypertension. Since 2005 we have used venoarterial extracorporeal membrane oxygenation (ECMO) support in this group that has no other therapeutic option. We review our experience of early ECMO support in the severely compromised patient's post-PTE.
We conducted a retrospective review of all patients undergoing PTE from a single national referral center between August 2005 and August 2007.
One hundred twenty-seven consecutive patients underwent PTE surgery. Seven patients (5.5%) had extreme cardiorespiratory compromise in the immediate postoperative period and required venoarterial ECMO support. Their mean age was 51.3 years with 3 males. When compared with patients not requiring ECMO, these patients had significantly poorer hemodynamic indices before the operation with mean pulmonary artery pressure of 62 mm Hg versus 51 mm Hg (p = 0.02) and pulmonary vascular resistance of 907 dynes/sec/cm(-5) versus 724 dynes/s(-1)/cm(-5) (p < 0.02). Mean duration of support was 119 hours (49 to 359 hours). Five patients were successfully weaned from ECMO support (73%) and 4 left the hospital alive, giving a salvage rate of 57%. For those who did not require ECMO support, hospital mortality was 4.2%.
Early venoarterial ECMO support has a role as rescue therapy post-PTE in patients with severe compromise who would probably otherwise die.
The Annals of thoracic surgery 10/2008; 86(4):1261-7. · 3.74 Impact Factor
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Robin Condliffe,
David G Kiely,
J Simon R Gibbs,
Paul A Corris,
Andrew J Peacock, David P Jenkins,
Denise Hodgkins,
Kim Goldsmith,
Rodney J Hughes,
Karen Sheares,
Steven S L Tsui,
Iain J Armstrong,
Chantal Torpy,
Rachel Crackett,
Christopher M Carlin,
Clare Das,
J Gerry Coghlan,
Joanna Pepke-Zaba
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ABSTRACT: The management of chronic thromboembolic pulmonary hypertension (CTEPH) has changed over recent years with the growth of pulmonary endarterectomy surgery and the availability of disease-modifying therapies.
To investigate the prognosis of CTEPH in a national setting during recent years.
All incident cases diagnosed in one of the five pulmonary hypertension centers in the United Kingdom between January 2001 and June 2006 were identified prospectively. Information regarding baseline characteristics, treatment, and follow-up was subsequently collected from hospital records.
A total of 469 patients received a diagnosis, of whom 148 (32%) had distal, nonsurgical disease. One- and three-year survival from diagnosis was 82 and 70% for patients with nonsurgical disease and 88 and 76% for those treated surgically (P = 0.023). Initial functional improvement in patients with nonsurgical disease was noted but did not persist at 2 years. Significant functional and hemodynamic improvements were seen in surgically treated patients with an increase in six-minute-walk distance of 105 m (P < 0.001) at 3 months. Five-year survival from surgery in the 35% of patients who survived to 3 months but had persistent pulmonary hypertension was 94%.
The prognosis in nonsurgical disease has improved. We have confirmed the previously described good outcome in surgically treated disease. However, we have also demonstrated that the long-term prognosis for patients who have persistent pulmonary hypertension at 3 months after surgery is good. The observed improvements in outcome during the modern treatment era reinforce the importance of identifying patients with this increasingly treatable condition.
American Journal of Respiratory and Critical Care Medicine 05/2008; 177(10):1122-7. · 11.08 Impact Factor
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ABSTRACT: Chronic thromboembolic pulmonary hypertension (CTEPH) results in severe symptoms and impaired survival. Pulmonary thromboendarterectomy (PTE) is considered the gold standard treatment. Many units have reported excellent early results post PTE, but there is less information on whether benefit is sustained. We sought to determine the medium-term functional and haemodynamic outcome for patients following PTE and the longer-term survival after discharge from hospital.
Data were collected prospectively on all patients who underwent PTE in the UK between 1997 and June 2006. Patients were reassessed at 3 and 12 months after operation. Follow-up over time was assessed using repeated measures ANOVA, the Friedman test or Wilcoxon signed ranks test as appropriate.
Two hundred and twenty-nine patients underwent PTE, survived to hospital discharge, and completed follow-up. At 3 months following operation, there was a significant reduction in mean pulmonary artery pressure (47+/-14 to 25+/-14mmHg, p<0.001), a significant increase in cardiac index (1.9+/-0.7 to 2.5+/-0.6l/minm(2), p<0.001) and a significant increase in 6-min walk distance (269+/-123 to 375+/-104m, p<0.001). At 12-month follow-up, the haemodynamic improvements were sustained and there was a further increase in 6-min walk distance (375+/-104 to 392+/-108m, p=0.004). NYHA class was significantly reduced at 3 months, with the improvement sustained at 12 months. Conditional survival following discharge from hospital was 92.5% at 5 years and 88.3% at 10 years.
PTE is a very effective therapy for CTEPH. This is the first report from a continuous national series to fully characterise haemodynamic and functional outcome 1 year after PTE. Patients enjoy continued improvement in haemodynamic status that translates into better exercise capacity, reduced symptoms and excellent survival.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 05/2008; 34(3):525-9; discussion 529-30. · 2.40 Impact Factor
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ABSTRACT: Pulmonary endarterectomy is the best treatment for patients with chronic thromboembolic pulmonary hypertension. Traditionally pulmonary endarterectomy has been performed utilising deep hypothermic circulatory arrest to provide a bloodless field, but some recent reports have challenged this concept. We reviewed our experience with selective antegrade cerebral perfusion as the initial strategy of controlling bronchial collateral flow to avoid complete circulatory arrest in patients undergoing pulmonary endarterectomy.
A retrospective review of all patients meeting the above criteria between July 2003 and June 2006. Selective antegrade cerebral perfusion at 20 degrees C was used as the initial means of reducing blood flow to the operative field.
One hundred and fifty-one patients (83 male, 68 female, mean age 56+/-16 years) were operated on using this strategy. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (142 of 151). At initial assessment, mean pulmonary artery pressure was 49+/-12 mmHg and mean pulmonary vascular resistance was 851+/-391 dynes s cm(-5). Selective antegrade cerebral perfusion was required in 145 for a total period of 63+/-24 min. Thirteen (9%) patients required conversion to deep hypothermic arrest for completion of the operation. In-hospital mortality was 22 (15%). There were no instances of focal neurological deficit. Prearranged clinical follow-up for 3 and 12 months was 97% complete with one late death by 3 months and one more by 12 months. The majority were in New York Heart Association class I or II at 3 months (102 of 115) and 12 months (65 of 74). At 3-month follow-up the mean pulmonary artery pressure was 27+/-10 mmHg and pulmonary vascular resistance was 304+/-220 dynes s cm(-5).
Overall results improved with era and institutional experience. The use of selective antegrade cerebral perfusion for pulmonary endarterectomy appears to be technically feasible in the majority of patients and is an alternative to complete circulatory arrest. To clarify its role further, comparison with deep hypothermic circulatory arrest in a randomised controlled trial is necessary.
European Journal of Cardio-Thoracic Surgery 03/2008; 33(2):157-63. · 2.55 Impact Factor
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ABSTRACT: Although pulmonary endarterectomy (PEA) is potentially curative in chronic thromboembolic pulmonary hypertension (CTEPH), some patients have distally distributed disease that is not amenable to surgery. The aetiology and characteristics of this patient group are currently not well understood.
This study compares the baseline demographic features and outcomes in subjects with distal CTEPH, those with proximal CTEPH and those with idiopathic pulmonary arterial hypertension (IPAH) to determine whether these conditions represent separate entities or whether they exist along the same spectrum of disease.
The medical history, clinical characteristics, bone morphogenetic protein receptor type II (BMPR2) mutation status and outcomes of 96 subjects with IPAH, 35 with distal CTEPH and 68 with proximal CTEPH referred to a single specialist centre between 1994 and 2005 were reviewed.
There were significant differences between the distal CTEPH, proximal CTEPH and IPAH groups in age (55.9 years vs 54.8 years vs 46.2 years, p<0.001), proportion who were male (43% vs 69% vs 29%, p<0.001), previous deep vein thrombosis (28.6% vs 30.9% vs 3.1%, p<0.001), positive BMPR2 status (0% vs 0% vs 15%, p = 0.018), mean pulmonary artery pressure (47.3 mm Hg vs 45.4 mm Hg vs 54.8 mm Hg, p<0.001) and total pulmonary resistance (12.9 WU vs 12.4 WU vs 18.1 WU, p<0.001). Patients with distal CTEPH and those with IPAH were managed similarly and had comparable survival characteristics (1 year survival 77% vs 86%; 3 year survival 53% vs 60%; p = 0.68).
Patients with distal CTEPH share certain demographic features with patients with proximal CTEPH that not only indicate a common aetiology but also help to differentiate them from patients with IPAH. Despite more favourable haemodynamic parameters in those with distal CTEPH, patients in this group had a poor long-term outcome which was similar to that of patients with IPAH.
Thorax 08/2007; 62(7):617-22. · 6.84 Impact Factor
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The Journal of thoracic and cardiovascular surgery 07/2006; 131(6):1410-1. · 3.41 Impact Factor
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[show abstract]
[hide abstract]
ABSTRACT: Objective: Chronic thromboembolic pulmonary hypertension (CTEPH) results in severe symptoms and impaired survival. Pulmonary thromboendarterectomy (PTE) is considered the gold standard treatment. Many units have reported excellent early results post PTE, but there is less information on whether benefit is sustained. We sought to determine the medium-term functional and haemodynamic outcome for patients following PTE and the longer-term survival after discharge from hospital. Methods: Data were collected prospectively on all patients who underwent PTE in the UK between 1997 and June 2006. Patients were reassessed at 3 and 12 months after operation. Follow-up over time was assessed using repeated measures ANOVA, the Friedman test or Wilcoxon signed ranks test as appropriate. Results: Two hundred and twenty-nine patients underwent PTE, survived to hospital discharge, and completed follow-up. At 3 months following operation, there was a significant reduction in mean pulmonary artery pressure (47 ± 14 to 25 ± 14 mmHg, p < 0.001), a significant increase in cardiac index (1.9 ± 0.7 to 2.5 ± 0.6 l/min m2, p < 0.001) and a significant increase in 6-min walk distance (269 ± 123 to 375 ± 104 m, p < 0.001). At 12-month follow-up, the haemodynamic improvements were sustained and there was a further increase in 6-min walk distance (375 ± 104 to 392 ± 108 m, p = 0.004). NYHA class was significantly reduced at 3 months, with the improvement sustained at 12 months. Conditional survival following discharge from hospital was 92.5% at 5 years and 88.3% at 10 years. Conclusions: PTE is a very effective therapy for CTEPH. This is the first report from a continuous national series to fully characterise haemodynamic and functional outcome 1 year after PTE. Patients enjoy continued improvement in haemodynamic status that translates into better exercise capacity, reduced symptoms and excellent survival.
European Journal of Cardio-Thoracic Surgery.
