Outcome of Medically Versus Surgically Treated Patients With Chronic Thromboembolic Pulmonary Hypertension (original) (raw)
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Circulation journal : official journal of the Japanese Circulation Society, 2018
Several new treatments for chronic thromboembolic pulmonary hypertension (CTEPH) have appeared in recent years, which have led to changes in the treatment algorithm. Changes in survival rates and prognostic factors, however, have not been estimated so far.Methods and Results:Two hundred and eighty patients were diagnosed with CTEPH at Chiba University Hospital between June 1986 and June 2016. Survival rate was investigated by date of treatment initiation (group 1, 1986-1998; group 2, 1999-2008; group 3, 2009-2016). Survival rates were also evaluated by treatment strategy: balloon pulmonary angioplasty (BPA), pulmonary endarterectomy (PEA), and medical treatment. Group 3 had significantly better disease-specific survival than groups 1 and 2 (5-year survival: 91.9% vs. 67.1%, 77.0%, respectively). For the non-PEA (BPA+medication) strategy, group 3 had better disease-specific survival than groups 1 and 2 (5-year survival: 94.9% vs. 54.6%, 74.2%, respectively). The PEA strategy had sign...
Pulmonary Circulation, 2012
Several prospective studies have reported that between 0.57% and 4.6% of acute pulmonary embolic survivors will develop symptomatic, chronic thromboembolic pulmonary hypertension (CTEPH). [1-3] As it is also reported that from 42% to 63% of patients with the established diagnosis of chronic thromboembolic disease have no previously documented acute venous thromboembolism, [4-6] the prevalence of CTEPH cases exceeds those estimates that have resulted from following patients with known thromboembolic events. The importance of correctly establishing the diagnosis of CTEPH is underscored by the understanding that, without appropriate therapy, patients with this disorder typically experience profound functional disability with a relatively poor long-term survivorship. [7,8] However, for selected CTEPH patients, pulmonary endarterectomy (PEA) surgery offers the potential for reversing the debilitating pulmonary hypertension and right heart failure that characterizes this disease. [9] The evaluation of patients with suspected chronic thromboembolic disease has the principal goal of identifying
Pulmonary Circulation
This study investigated whether residual pulmonary hypertension (PH), defined as early postoperative mean pulmonary artery pressure (mPAP) of ≥30 mmHg, after undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) was associated with longterm survival. All patients who underwent PEA for CTEPH at two Scandinavian centers were included in this study. Baseline characteristics and vital statuses were obtained from patient charts and national health-data registers. The patients were then categorized based on residual PH measured via right heart catheterization within 48 h after undergoing PEA. Crude and weighted flexible parametric survival models were used to estimate the association between residual PH and all-cause mortality and to quantify absolute survival differences. From 1992 to 2020, 444 patients underwent surgery. We excluded 6 patients who died on the day of surgery and 12 patients whose early postoperative pulmonary hemodynamic data was unavailable. Of the total study population (n = 426), 174 (41%) and 252 (59%) patients had an early postoperative mPAP <30 and ≥30 mmHg, respectively. After weighting, there was a significant association between residual PH and all-cause mortality (hazard ratio: 2.49; 95% confidence interval [CI]: 1.60-3.87), and the absolute survival difference between the groups at 10 and 20 years was-22% (95% CI:-32% to-12%) and-32% (95% CI:-47% to-18%), respectively. A strong and clinically relevant association of residual PH with long-term survival after PEA for CTEPH was found. After accounting for differences in baseline characteristics, the absolute survival difference at long-term follow-up was clinically meaningful and imply careful surveillance to improve clinical outcomes in these patients. Early postoperative right heart catheter
The Journal of Thoracic and Cardiovascular Surgery, 2011
Objective: Pulmonary endarterectomy is a curative surgical treatment option for the majority of patients with chronic thromboembolic pulmonary hypertension. The current surgical management and postoperative outcome of patients enrolled in an international registry on chronic thromboembolic pulmonary hypertension were investigated. Methods: The registry included newly diagnosed (6 months) consecutive patients with chronic thromboembolic pulmonary hypertension from February 2007 to January 2009. Results: A total of 679 patients were registered from 1 Canadian and 26 European centers, of whom 386 (56.8%) underwent surgery. The median age of patients undergoing surgery was 60 years, and 54.1% were male. Previous pulmonary embolism was confirmed for 79.8% of patients. Perioperative complications occurred in 189 patients (49.2%): infection (18.8%), persistent pulmonary hypertension (16.7%), neurologic (11.2%) or bleeding (10.2%) complications, pulmonary reperfusion edema (9.6%), pericardial effusion (8.3%), need for extracorporeal membrane oxygenation (3.1%), and in-hospital mortality due to perioperative complications (4.7%). Documented 1-year mortality was 7%. Preoperative exercise capacity was predictive of 1-year mortality. Postoperative pulmonary vascular resistance predicted in-hospital and 1-year mortality. In patients evaluated within 1 year after surgery, the median pulmonary vascular resistance had decreased from 698 to 235 dyn.s.cm À5 (95% confidence limit, 640-874 and 211-255, respectively, n ¼ 70) and the median 6-minute walk distance had increased from 362 to 459 m (95% confidence limit, 340-399 and 440-473, respectively, n ¼ 168). New York Heart Association functional class improved with most patients progressing from class III/IV to class I/II. Conclusions: Pulmonary endarterectomy is associated with a low in-hospital mortality rate and improvements in hemodynamics and exercise capacity.
C hronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism with uncertain prevalence, ranging from 0.4% to 9.1%. 1 Diagnosis is strongly associated with a history of acute venous thromboembolism (VTE). 2,3 It is caused by nonresolving fibrothrombotic obstructions of large pulmonary arteries, combined Background-Chronic thromboembolic pulmonary hypertension, a rare complication of acute pulmonary embolism, is characterized by fibrothrombotic obstructions of large pulmonary arteries combined with small-vessel arteriopathy. It can be cured by pulmonary endarterectomy, and can be clinically improved by medical therapy in inoperable patients. A European registry was set up in 27 centers to evaluate long-term outcome and outcome correlates in 2 distinct populations of operated and not-operated patients who have chronic thromboembolic pulmonary hypertension. Methods and Results-A total of 679 patients newly diagnosed with chronic thromboembolic pulmonary hypertension were prospectively included over a 24-month period. Estimated survival at 1, 2, and 3 years was 93% (95% confidence interval [CI], 90-95), 91% (95% CI, 87-93), and 89% (95% CI, 86-92) in operated patients (n=404), and only 88% (95% CI, 83-91), 79% (95% CI, 74-83), and 70% (95% CI, 64-76) in not-operated patients (n=275). In both operated and not-operated patients, pulmonary arterial hypertension-targeted therapy did not affect survival estimates significantly. Mortality was associated with New York Heart Association functional class IV (hazard ratio [
2021
Chronic thromboembolic pulmonary hypertension occurs when blood clots in the lungs do not resolve. This causes the pressure in the lungs to rise and without treatment it is a serious condition which reduces life expectancy. It occurs in approximately 1 in 20 patients who have had a lung clot (also known as a pulmonary embolism). The condition can be potentially cured by an operation called pulmonary endarterectomy where the chronic lung clots are removed. However, not all patients are suitable for the operation and some patients who are suitable for the operation decline surgery. This study identifies a number of tests that can be used to identify patients at highest risk of dying and shows that surgery provides very good long term results which are superior to those who decline surgery. The results of this study will help doctors and patients with CTEPH when discussing treatment options. The authors conclude that more work is required to ensure that patients are counselled and supp...
Predictors of mortality in inoperable chronic thromboembolic pulmonary hypertension
Respiratory Medicine, 2009
KEYWORDS Chronic thromboembolic pulmonary hypertension; Prognostic factors; Survival Summary Introduction: Recent studies suggest that medically treated patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) have an improved prognosis. However, only limited data are available concerning predictors of mortality in these patients. The aim of this study was to assess, and to identify, predictors of the long-term outcome of inoperable CTEPH patients. Methods: We analysed 84 inoperable CTEPH patients referred to our centre between 1999 and 2008. During follow-up (mean 32 months), 17 patients died and one underwent a lung transplantation. The 1-, 3-and 5-year survival rates were 93, 78 and 68%, respectively. Univariate analysis demonstrated that 6-min walking distance (6MWD), mean pulmonary artery pressure (mPAP), right atrial pressure (RAP) and pulmonary vascular resistance (PVR) were predictive factors for survival. In the multivariate analysis only 6MWD was independently related to poor survival (hazard ratio 0.995; 95% CI, 0.991e0.998; P Z 0.003). KaplaneMeier curves showed that patients with an mPAP > 40 mmHg, PVR > 584 dyn s cm À5 and RAP > 12 mmHg had a very poor prognosis. Conclusions: Haemodynamic parameters (mPAP, RAP, PVR) and the 6MWD at baseline are predictive factors for mortality of medically treated inoperable CTEPH patients. A subgroup Abbreviations: 6MWD, 6-min walking distance; AMC, associated medical conditions; CTEPH, chronic thromboembolic pulmonary hypertension; ERA, endothelin receptor antagonist; mPAP, mean pulmonary artery pressure; NT-proBNP, N-terminal pro brain natriuretic peptide; PDE-5 inhibitor, phosphodiesterase-5 inhibitor; PVR, pulmonary vascular resistance; PEA, pulmonary endarterectomy; RAP, right atrial pressure; ROC, receiver operating characteristics; RVP, right ventricular pressure; SvO 2 , mixed venous oxygen saturation. a v a i l a b l e a t w w w . s c i e n c e d i r e c t . c o m j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / r m e d Respiratory Medicine (2009) 103, 1013e1019 of these patients with good prognostic factors, defined by their haemodynamics and clinical measures, have an improved long-term survival and outcome. Crown