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CTEPH CASI CLINICI

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CTEPH CASI CLINICI, IPERTENSIONE POLMONARE CRONICA TROMBOEMBOLICA

CTEPH CASI CLINICI, IPERTENSIONE POLMONARE CRONICA TROMBOEMBOLICA

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  • 1. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH P. F. #255 XX-XX-1949 ITALIAN VARESE HOUSE PAINTER 150 cm 48 Kg Systemic arterial hypertension Gastroesophageal reflux diseaseUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 2. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH JUNE 2004 Onset of mild dyspnea (WHO II) JUNE 2005 Worsening of dyspnea (WHO III) JULY 2005 Admission to the Cardiology ward of a local hospital • ECG: right ventricle overload • Echocardiogram: dilation and hypokinesia of the right chambers severe tricuspid regurgitation CTEPH severe pulmonary hypertension (sPAP 85 mmHg) • Lung V/Q scan: bilateral mismatches with multiple perfusion defects • HRCT scan: multiple bilateral segmental perfusion defects • Venous echocolordoppler of lower limbs : negativeUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 3. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH SEPTEMBER 2005 Admission to our Division for operability assessment • COMPLETE DIAGNOSTIC WORKUP: CTEPH CONFIRMED • Right Heart Catheterization: RA 1 mmHg RV 82 / 0 mmHg PA 82 / 39 / 13 mmHg PCWP 3 mmHg CO 3.3 L/min CI 2.2 L/min RVEF 25 % PVRP 873 dyn*s*cm-5 • OPERABILITY: INOPERABLE FOR EXCLUSIVELY DISTAL DISEASE DOUBLE LUNG TRANSPLANT WAITING LISTUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 4. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH LUNG V/Q SCAN VENTILATION PERFUSIONUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 5. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH PULMONARY ANGIOGRAMUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 6. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH HRCT SCANUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 7. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH DECEMBER 2005 Enrollment in the BENEFIT study (bosentan vs. placebo in inoperable forms of CTEPH) INOPERABILITY CONFIRMED BY THE INTERNATIONAL COMMITTEE Enrollment End of study (16 weeks) Open label extension 27-DEC-2005 28-APR-2006 26-OCT-2006 RA 4 4 6 mmHg RV 82/2 82/0 85/3 mmHg PA 82/46/24 82/45/22 85/49/28 mmHg PCWP 5 5 5 mmHg CO 3.1 2.4 3.0 L/min CI 2.1 1.6 2.0 L/min/m2 RVEF 34 11 12 % PVR 1057 1343 1164 dyn*s*cm-5 Serum-BNP 360 324 151 pg/ml WHO III III IIUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 8. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH BENEFIT and BENEFIT-OPEN LABEL EXTENSION Clinical course 6mWT 15-FEB-2008 Withdrawal from DLTx waiting list 600 480 456 462 500 442 418 400meters 290 270 300 200 WHO III WHO II 100 BENEFIT BENEFIT-Open Label 0 Dec-05 Apr-06 Oct-06 May-07 Oct-07 May-08 Jan-09 Follow-upUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 9. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH OCTOBER 2009 Worsening of dyspnea (back to WHO III) NOVEMBER 2009 Admission to our Division for therapy update NEW OPERABILITY ASSESSMENT → NOW TECHNICALLY OPERABLE (JUST ALIKE THE PREVIOUS FINDINGS) BILATERAL PULMONARY ENDARTERECTOMY Right: upper, middle and lower lobe Left: upper lobe, lingula and lower lobe Moderate hypothermia (23 C) Intermittent circulatory arrests right side: 91 min left side: 47 min total time: 138 minUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 10. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH BILATERAL PEA – SURGICAL SPECIMENUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 11. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH BILATERAL PEA Early postoperative outcome • Invasive mechanical ventilation < 24 h • Assisted normal breathing with continuous positive pressure (cPAP) (to avoid reperfusion lung edema) • ICU stay: 2 days (fast-track recovery program) • Total postoperative hospital stay: 16 daysUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 12. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH BILATERAL PEA Hemodynamic results Preoperative At discharge 3 months FUP 27-NOV-2009 15-DEC-2009 26-FEB-2010 RA 7 3 3 mmHg RV 120/0 53/0 35/0 mmHg PA 120/65/36 53/22/8 35/19/12 mmHg PCWP 5 5 5 mmHg CO 3.5 3.9 4.2 L/min CI 2.4 2.7 2.9 L/min/m2 RVEF 6 18 21 % PVR 1371 308 267 – 81 % dyn*s*cm-5 Serum-BNP 996 742 106 pg/ml WHO III I IUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 13. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III The “seasoned veteran” SPECIFIC MEDICAL THERAPY PULMONARY ENDARTERECTOMY TRANSPLANT (Gold Standard) WAITING LIST SPECIFIC PAH-DRUG DISCONTINUATIONDIAGNOSIS UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 14. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case P. B. #250 XX-XX-1934 (75 y) ITALIAN TURIN PENSIONER 178 cm 72 KgUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 15. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case MEDICAL HISTORY • Congenital single kidney (right) • Sigmoid diverticulosis • Bilateral cataract • 2000: colonscopy polyp removal SEPTEMBER 2009 Onset of mild dyspnea (WHO II) and right thoracic pain OCTOBER 2009 Acute dyspnea (WHO IV) → admission to the Emergency WardUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 16. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case OCTOBER 2009 Emergency ward diagnostic workup • ECG: right ventricle overload • Echocardiogram: CTEPH dilation and hypokinesia of the right chambers paradoxical movement of the interventricular septum severe tricuspid regurgitation severe pulmonary hypertension (sPAP 90 mmHg) • HRCT scan: multiple bilateral segmental perfusion defects NOVEMBER 2009 Admission to our Division for operability assessmentUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 17. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case THROMBOPHILIA AND HYPERCOAGULABILITY Laboratory findings • Hyperhomocysteinemia • Excess Factor VIII • Prothrombin gene mutation (G20210A – Factor II) • Homocysteine methabolism gene mutation (C677T – MTHFR) • Homocysteine methabolism gene mutation (A1298C – MTHFR) Echocolordoppler of the lower limbs • Previous bilateral deep venous thrombosisUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 18. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case OPERABILITY ASSESSMENT Lung V/Q scan • Massive bilateral perfusion defects (mainly at left upper lobe, lingula and right upper lobe) • Quantitative perfusion map: left 38% – right 62% Pulmonary angiogram • Right upper lobe occlusion • Right inferior segmental middle lobe occlusion • Right posterior segmental lower lobe occlusion • Left anterior and posterior segmental upper lobe occlusion • Left lower lobe occlusionUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 19. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case OPERABILITY ASSESSMENT HRCT scanUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 20. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case OPERABILITY ASSESSMENT Hemodynamic Preoperative 06-NOV-2009 RA 2 RV 78/0 PA 78/38/15 PCWP 5 CO 4.4 CI 2.3 RVEF 36 PVR 600 Serum-BNP 70 WHO IIIUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 21. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case COLLATERAL FINDINGS Echocolordoppler of the neck vessels • 55% right common – internal carotid artery stenosis • 65% left common – internal carotid artery stenosis Coronary angiogram • Left main coronary artery ostial stenosis (80%) • LAD, 1st Diagonal, 2nd Diagonal and Circumflex stenosis • Normal right coronary artery Echocardiogram • Moderate aortic regurgitationUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 22. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case OPERATION BILATERAL PULMONARY ENDARTERECTOMY Right: upper, middle and lower lobe Left: upper lobe, lingula and lower lobe Moderate hypothermia (24 C) Intermittent circulatory arrests right side: 50 min left side: 30 min total time: 80 min CORONARY ARTERY BYPASS GRAFTING Right great saphenous vein on LAD and Circumflex AORTIC VALVE REPLACEMENT Carpentier-Edwards® Aortic Porcine BioprosthesisUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 23. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case BILATERAL PEA – SURGICAL SPECIMENUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 24. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case BILATERAL PEA Early postoperative outcome • Invasive mechanical ventilation < 24 h • Assisted normal breathing with continuous positive pressure (cPAP) (to avoid reperfusion lung edema) • ICU stay: 2 days (fast-track recovery program) • Total postoperative hospital stay: 10 daysUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 25. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA IN THE ELDERLY A peculiar case BILATERAL PEA Hemodynamic results Preoperative At discharge 3 months FUP 06-NOV-2009 18-NOV-2009 18-FEB-2010 RA 2 3 5 mmHg RV 78/0 26/0 30/0 mmHg PA 78/38/15 26/11/5 30/18/9 – 53 % mmHg PCWP 5 5 5 mmHg CO 4.4 4.2 4.9 + 11 % L/min CI 2.3 2.2 2.7 L/min/m2 RVEF 36 40 36 % PVR 600 114 212 – 65 % dyn*s*cm-5 Serum-BNP 70 186 66 pg/ml WHO III I IUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 26. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case T. S. #108 XX-XX-1983 ITALIAN GENOA STUDENT 162 cm 79 Kg Thrombosis risk factors Sedentary lifestyleUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 27. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MEDICAL HISTORY• Obesity (BMI > 30 kg/m2) – Hormonal contraception – Active smoker ( 20 cig / day)• Recent car accident injuries without adequate venous thromboembolism prophylaxis• Coagulative disorders (hyperhomocysteinemia with C677T and A1298C gene mutation, excess plasminogen activator inhibitor) NOVEMBER 2003 Acute pulmonary embolism THROMBOLYSIS Right: partial embolic obstruction of the main pulmonary artery Left: total embolic occlusion of the main pulmonary arteryUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 28. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case APRIL 2004 HRCT scan Despite thrombolysis and 6 months of full oral anticoagulation therapy Right: patent pulmonary artery Left: persisting subtotal embolic obstruction of the main pulmonary arteryUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 29. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case APRIL 2004 Complete diagnostic workup LUNG V/Q SCAN VENTILATION PERFUSIONUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 30. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case APRIL 2004 Complete diagnostic workup HEMODYNAMIC Preoperative 07-APR-2004 RA 6 RV 33/0 PA 29/20/12 PCWP 4 CO 6.7 CI 3.6 RVEF 55 PVR 191 Serum-BNP 20 WHO IIUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 31. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case APRIL 2004 Complete diagnostic workup PULMONARY ANGIOGRAM • Radiologic features • Failure of anticoagulation on the left obstruction • Normal hemodynamic despite severe perfusion defect DIFFERENTIAL DIAGNOSIS LEFT PULMONARY ARTERY ANGIOSARCOMA ?UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 32. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case APRIL 2004 Complete diagnostic workup DIFFERENTIAL DIAGNOSIS LEFT PULMONARY ARTERY ANGIOSARCOMA ? INTRAVASCULAR BIOPSY • Unfortunately unsuccessful • Undetermined diagnosisUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 33. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case LEFT UNILATERAL PEA – INTRAOPERATIVE DIAGNOSIS • At surgical inspection the endoluminal material appeared to be thromboembolic • A left unilateral PEA was performed • Diagnosis confirmed by histological examination • Uncomplicated postoperative recovery Invasive Mechanical Ventilation < 24 h ICU stay 2 days Total postoperative hospital stay 8 daysUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 34. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case LEFT UNILATERAL PEA Hemodynamic results Preoperative At discharge 07-APR-2004 26-APR-2004 RA 6 3 mmHg RV 33/0 29/0 mmHg PA 29/20/12 29/13/2 – 35 % mmHg PCWP 4 5 mmHg CO 6.7 7.5 + 12 % L/min CI 3.6 4.1 L/min/m2 RVEF 55 53 % PVR 191 85 – 55 % dyn*s*cm-5 Serum-BNP 20 91 pg/ml WHO II IUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 35. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case DISCUSSION • The hospitalization due to car accident injuries may have been complicated by a left pulmonary thromboembolism • The patient could have been asymptomatic because of her sedentary lifestyle • A second acute pulmonary thromboembolism on the right side could have revealed the previously asymptomatic disease • Even if oral anticoagulation relieved most of symptoms and hemodynamic was normal, we deemed the patient a potential candidate for PEA • The aim was to prevent the inexorable evolution of chronic thromboembolic lesions into CTEPH with vascular remodeling of the patent branchesUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 36. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case P. G. #146 XX-XX-1944 ITALIAN CREMONA SPORTSMAN 180 cm 83 KgUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 37. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MEDICAL HISTORY• 1996: onset of exertional angina (negative cardiopulmonary exercise test)• 2001: acute pulmonary embolism → oral anticoagulation therapy• 2002 → 2006: regular echocardiographic controls showing the progressive onset of PH• 2006: onset of exertional dyspnea (WHO II) MAY 2006 Admission to our Division for operability assessmentUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 38. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MAY 2006 Complete diagnostic workup LUNG V/Q SCAN VENTILATION PERFUSIONUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 39. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MAY 2006 Complete diagnostic workup HEMODYNAMIC Preoperative 11-MAY-2006 RA 4 RV 84/3 PA 84/45/20 PCWP 5 CO 2.9 CI 1.4 RVEF 18 PVR 1103 Serum-BNP 140 WHO IIUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 40. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MAY 2006 Complete diagnostic workup PULMONARY ANGIOGRAMUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 41. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case MAY 2006 Complete diagnostic workup HRCT SCANUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 42. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case BILATERAL PEA – SURGICAL SPECIMENUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 43. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case BILATERAL PEA Hemodynamic results Preoperative At discharge 4 years FUP 11-MAY-2006 26-MAY-2006 12-MAR-2010 RA 4 0 5 mmHg RV 84/3 15/0 29/0 mmHg PA 84/45/20 15/12/6 29/18/9 – 60 % mmHg PCWP 5 3 5 mmHg CO 2.9 3.9 4.5 – 55 % L/min CI 1.4 2.0 2.3 L/min/m2 RVEF 18 25 39 % PVR 1103 185 231 – 79 % dyn*s*cm-5 Serum-BNP 140 82 12 pg/ml WHO II I IUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 44. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II A peculiar case DISCUSSION • Anticoagulation after the acute pulmonary embolism was probably not completely effective • The incomplete resolution of organized pulmonary emboli resulted in progressive right heart failure • Due to his high exercise tolerance, the patient became symptomatic only when the severe pulmonary hemodynamic jeopardized the left heart function (cardiac index of 1.4 L/min/m2) • Hemodynamic and radiologic features of the disease were both impressive despite paucity of symptomsUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY