IPERTENSIONE POLMONARE CRONICA TROMBOEMBOLICA, CTEPH

1. Andrea M D’Armini, MD, FCCP CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION FROM TRANSPLANT TO CONSERVATIVE SURGERY Cardiac Surgery University of Pavia School of Medicine Foundation I.R.C.C.S. “San Matteo” Hospital Pavia, Italy

2. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY BACKGROUND Chronic Thromboembolic Pulmonary Hypertension Acute Pulmonary Embolism

9. U. G. PRE DLTx U. G. 1° POST DLTx DLTx for FAMILIAL PULMONARY HYPERTENSION SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY THORACIC TRANSPLANTATION 1355 TRANSPLANTS (17/11/1985 – 19/05/2011)

10. DLTx for FAMILIAL PULMONARY HYPERTENSION RIGHT HEART CATHETERIZATION PRE-DLTx 1° POST-DLTx Right Atrium 13 9 Right Ventricle 118/0 25/0 Pulmonary Arterial Pressure 118/82/60 38/25/16 ( -70% ) Systemic Arterial Pressure 96/76/61 113/73/53 Pulmonary Capillary Wedge Pressure 5 10 Cardiac Output 2.9 6.2 ( +114% ) Cardiac index 1.6 4.0 Pulmonary Vascular Resistance 2134 155 ( -91% ) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY THORACIC TRANSPLANTATION 1355 TRANSPLANTS (17/11/1985 – 19/05/2011)

11. HLTx for EISENMENGER’S SYNDROME M. P. PRE HLTx M. P. 1° POST HLTx SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY THORACIC TRANSPLANTATION 1355 TRANSPLANTS (17/11/1985 – 19/05/2011)

12. HLTx for EISENMENGER’S SYNDROME SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY THORACIC TRANSPLANTATION 1355 TRANSPLANTS (17/11/1985 – 19/05/2011) Systolic Pulmonary Arterial Pressure 105 mmHg Right Ventricular End-Diastolic Diameter 110 mm Inferior Vena Cava 34 mm PRE-OPERATIVE ECHOCARDIOGRAPHY Right Atrium 6 mmHg Right Ventricle 23/0 mmHg Pulmonary Arterial Pressure 23/11/6 mmHg Pulmonary Capillary Wedge Pressure 6 mmHg Cardiac Output 7.1 L/min Cardiac Index 4.3 L/min/m 2 Pulmonary Vascular Resistance 45 dyne*sec*cm -5 POST-OPERATIVE RIGHT HEART CATHETERIZATION

18. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY COAGULATIVE DISORDERS 150.0 – 334.0 182.1 ± 46.6 47.6 % EXCESS FACTOR VIII RISTOCETIN (%) 0.50 – 1.99 1.34 ± 0.55 15.3 % FACTOR V LEIDEN 3.6 – 7.9 5.1 ± 1.2 53.2 % PAI EXCESS (U/ml) 153.4 – 220.0 179.3 ± 25.8 27.4 % EXCESS FACTOR VIII (%) 161.1 – 392.9 206.7 ± 33.9 78.2 % EXCESS FACTOR VIII ANTIGEN (%) 14.1 – 63.2 21.7 ± 8.3 72.6 % HYPERHOMOCYSTEINEMIA ( μ mol/L) RANGE MEAN ± SD % PTS DISORDER

19. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY IMMUNOLOGIC DISORDERS 8.4 – 121.0 63.2 ± 36.5 14.5 % Anti-Phospholipid Antibodies (APA) IgG 10.1 – 91.3 28.0 ± 23.5 12.9 % Anti-Phospholipid Antibodies (APA) IgM 10.3 – 121.0 56.3 ± 40.3 20.2 % Anti-Cardiolipin Antibodies (ACA) IgG – – 8.9 % Positive Direct Coombs’ Test 7.3 – 101.0 30.8 ± 30.5 13.7 % Anti-Cardiolipin Antibodies (ACA) IgM – – 19.4 % Lupus Anticoagulant (LAC) – – 23.4 % Anti-Nuclear Antibodies (ANA) RANGE MEAN ± SD % PTS DISORDER

22. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CLINIC The clinical indication changes substantially according to the different surgical treatment of CTEPH

26. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ANATOMY PROXIMAL LESIONS

27. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY M.B. – 62 yrs M – Jul 2001 – PEA #64 Perfusion and ventilation scan Pulmonary angiogram Hemodynamic mPAP 67 CI 1.6 PVR 1766

28. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ANATOMY DISTAL LESIONS

29. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY S.S. – 31 yrs M – Sep 2002 Perfusion and ventilation scan Pulmonary angiogram Hemodynamic mPAP 50 CI 1.8 PVR 1120

31. Concomitant severe parenchymal lung disease is the real absolute contraindication to PEA Such patients are not suitable for PEA and must be listed for DLTx (if indicated) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CONTRAINDICATION TO PEA

32. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY P.B. – 60 yrs M – Jun 2002 Perfusion and ventilation scintigraphy Pulmonary angiography CT scan Hemodynamic mPAP 28 CI 1.9 PVR 645

33. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY REFERENCE

36. 65 PEAs in almost 8 yrs 65 PEAs in 1 yr SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY SURGICAL TREATMENT OF CTEPH PAVIA EXPERIENCE - 356 PEAs

37. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY MAIN WORLD PEA CENTERS Paris, France ≈ 100 PEAs / year NATIONAL REFERRAL PROGRAM FOR EXCELLENCE Cambridge, UK ≈ 80 PEAs / year NATIONAL REFERRAL PROGRAM BY LAW Pavia, Italy ≈ 60 PEAs / year MORE THAN ONE PROGRAM Bad Nauheim, Germany ≈ 50 PEAs / year MORE THAN ONE PROGRAM San Diego, California, USA ≈ 130 PEAs / year NATIONAL REFERRAL PROGRAM FOR EXCELLENCE

38. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY SURGICAL TREATMENT OF CTEPH 08-MAR-1991 First HLTx for CTEPH 11-APR-1994 First PEA 28-JUL-2003 First PEA in patient listed for DLTx 25-DEC-1995 First DLTx for CTEPH

39. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY TRANSPLANT FOR CTEPH 18 / 79 MORE DIAGNOSIS MORE DISTAL PEAs

40. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY AMOUNT OF PATIENTS NEW EVALUATIONS + 100%

41. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY AMOUNT OF PATIENTS DIAGNOSTIC ACCURACY 63% 76% + 13%

42. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY AMOUNT OF PATIENTS OPERABILITY RATE 74% 89% + 15%

43. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY AMOUNT OF PATIENTS PEAs PERFORMED + 195 %

47. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY PEA POPULATION OF 356 PEAs

48. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ECHOCARDIOGRAPHY

49. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CARDIAC MAGNETIC RESONANCE

50. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ARTERIAL BLOOD GASES OF 356 PEAs

51. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY MODIFIED BRUCE TEST OF 356 PEAs

52. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CARDIOPULMONARY EXERCISE TESTING OF 200 PEAs

53. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CARDIOPULMONARY EXERCISE TESTING OF 200 PEAs

54. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY PULMONARY ENDARTERECTOMY

55. E.L. – 38 yrs M – Dec 1999 – PEA #42 mPAP 43  20 (-53%) CO 3.3  6.9 (+109%) PVR 994  220 (-78%) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY TYPICAL SURGICAL SPECIMENS P.A. – 66 yrs M – Jun 2001 – PEA #60 mPAP 50  25 (-50%) CO 2.6  4.4 (+69%) PVR 1385  364 (-74%)

56. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY DISTAL LESIONS JAMIESON TYPE III LEARNING CURVE

57. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE I vs. TYPE II vs. TYPE III L.M.E.L. - 65 yrs M - Oct 2004 - PEA #119 mPAP 39  19 (-51%) CO 4.4  5.4 (+23%) PVR 665  222 (-66%) G.A.C. - 52 yrs F - Jul 2003 - PEA #96 mPAP 48  27 (-44%) CO 2.1  4.2 (+100%) PVR 1638  381 (-77%) B.A. - 43 yrs F - May 2009 - PEA #233 mPAP 49  19 (-61%) CO 3.3  5.0 (+52%) PVR 1067  224 (-79%)

58. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III B.A. - 43 yrs F - May 2009 - PEA #233 mPAP 49  19 (-61%) CO 3.3  5.0 (+52%) RVEF 16  35 (+119%) PVR 1067  224 (-79%)

59. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT F.C. - 33 yrs F - Apr 2009 - PEA #225 mPAP 52  20 (-62%) CO 4.6  4.7 (+2%) RVEF 32  41 (+28%) PVR 870  255 (-71%) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III

60. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT B.R.A. - 72 yrs F mPAP 44 CO 2.9 RVEF 28 PVR 1159 SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY INOPERABILE CTEPH?

61. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT B.R.A. - 72 yrs F - Mar 2009 - PEA #222 mPAP 44  33 (-25%) CO 2.9  4.9 (+69%) RVEF 28  34 (+21%) PVR 1159  457 (-61%) B.R.A. - 72 yrs F mPAP 44 CO 2.9 RVEF 28 PVR 1159 SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON’S TYPE III DISEASE

62. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT G.G. - 62 yrs F mPAP 51 CO 2.6 RVEF 19 PVR 1415 SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY INOPERABILE CTEPH?

63. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT G.G. - 62 yrs F - Sep 2009 - PEA #240 mPAP 51  27 (-47%) CO 2.6  4.0 (+54%) RVEF 19  24 (+26%) PVR 1415  460 (-68%) G.G. - 62 yrs F mPAP 51 CO 2.6 RVEF 19 PVR 1415 SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON’S TYPE III DISEASE

65. A peculiar case: a “seasoned veteran” in CTEPH SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III XX-XX-1949 ITALIAN VARESE HOUSE PAINTER 150 cm 48 Kg Systemic arterial hypertension Gastroesophageal reflux disease P. F. #255

68. LUNG V/Q SCAN SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH VENTILATION PERFUSION

69. PULMONARY ANGIOGRAM SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH

70. HRCT SCAN SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH

71. DECEMBER 2005 Enrollment in the BENEFIT study (bosentan vs. placebo in inoperable forms of CTEPH) INOPERABILITY CONFIRMED BY THE INTERNATIONAL COMMITTEE SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH Enrollment 27-DEC-2005 End of study (16 weeks) 28-APR-2006 Open label extension 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/m 2 RVEF 34 11 12 % PVR 1057 1343 1164 dyn*s*cm -5 Serum-BNP 360 324 151 pg/ml WHO III III II

72. BENEFIT and BENEFIT-OPEN LABEL EXTENSION Clinical course SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH 15-FEB-2008 Withdrawal from DLTx waiting list WHO III WHO II BENEFIT-Open Label BENEFIT

73. 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 min 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 ) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH

74. BILATERAL PEA – SURGICAL SPECIMEN SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH

75. – 81 % BILATERAL PEA Hemodynamic results SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III A peculiar case: a “seasoned veteran” in CTEPH Preoperative 27-NOV-2009 At discharge 15-DEC-2009 3 months FUP 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/m 2 RVEF 6 18 21 % PVR 1371 308 267 dyn*s*cm -5 Serum-BNP 996 742 106 pg/ml WHO III I I

76. The “seasoned veteran” DIAGNOSIS TRANSPLANT WAITING LIST SPECIFIC MEDICAL THERAPY PULMONARY ENDARTERECTOMY (Gold Standard) SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY JAMIESON TYPE III SPECIFIC PAH-DRUG DISCONTINUATION

77. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CUMULATIVE PROPORTION SURVIVING OF 356 PEAs Operative mortality Global 32/356 (9.0%) NYHA II 0/32 (0.0%) NYHA III 8/165 (4.8%) NYHA IV 24/159 (15.1%) Jan 08 – May 11 13/182 (7.1%) 187 144 125 108 91 71 54 42 33 30 22 14 7 3 2 89.2  1.9 87.1  2.2 86.5  2.2 85.6  2.4 84.5  2.6 83.1  2.9 81.6  3.2 79.2  3.9 79.2  3.9

78. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CUMULATIVE PROPORTION SURVIVING 45 PTS ON WAITING LIST FOR TRANSPLANT IN CTEPH

79. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CUMULATIVE PROPORTION SURVIVING 18 TRANSPLANTS IN CTEPH

80. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY FOLLOW-UP In literature few data are reported on mid- and long- term cardiopulmonary function, particularly on exertion, and on clinical outcomes after PEA

82. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY NYHA FUNCTIONAL CLASS Pre-op 3m 1y 3y 5y 7y 10y p < 0.01

83. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY mean PULMONARY ARTERY PRESSURE p < 0.01 Pre-op disch 3m 1y 3y 5y 7y 10y

84. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY PULMONARY VASCULAR RESISTANCES p < 0.01 Pre-op disch 3m 1y 3y 5y 7y 10y

85. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ECHOCARDIOGRAPHY Before PEA

86. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ECHOCARDOGRAPHY First echo after PEA – POD #9

87. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ECHOCARDIOGRAPHY 3-months FUP after PEA

88. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CARDIAC MAGNETIC RESONANCE Before PEA First CMR after PEA – POD #6

89. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CARDIAC MAGNETIC RESONANCE 4-years FUP after PEA First CMR after PEA – POD #6

90. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY ARTERIAL OXYGEN PARTIAL PRESSURE p < 0.01 Pre-op 3m 1y 3y 5y 7y 10y

91. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY MODIFIED BRUCE TEST p < 0.01 Pre-op 3m 1y 3y 5y 7y 10y

94. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MEDICAL THERAPY INOPERABLE CTEPH OR RECURRENT PH AFTER PEA

96. Pre-operative V/Q scan Pre-operative right pulmonary angiogram Pre-operative RHC mPAP 50 CI 1.4 PVR 1241 RVEF 9 Extensive obstruction of the right proximal PA branches; only sub-segmental lesions on the left PA PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PRE-OPERATIVE LONG LASTING DISEASE

101. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE HIGHER ENROLLING CENTERS FEATURES National referral program Higher patients amount Higher operability rate ANYWAY number of inoperable patients won’t be affected CLINICAL TRIAL TARGETS

102. Higher operability rate PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE HIGHER ENROLLING CENTERS FEATURES More Jamieson type III PEAs CLINICAL TRIAL TARGETS Higher PH recurrence after PEA

103. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PH – MEDICAL THERAPHY

104. No drugs are currently approved for CTEPH PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CTEPH – MEDICAL THERAPHY Further clinical trials are needed

105. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY

107. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY Jaïs X, D’Armini AM, Jansa P et al. J Am Coll Cardiol 2008 Dec 16;52(25):2127-34

108. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY Jaïs X, D’Armini AM, Jansa P et al. J Am Coll Cardiol 2008 Dec 16;52(25):2127-34

109. *Analysis excluded patients judged operable by the Operability Evaluation Committee (n=11) † Analysis excluded patients with missing baseline or post-baseline assessment(s) (n=9 for pulmonary vascular resistance [PVR] analysis; n=6 for 6-min walk distance [6MWD] analysis) mPAP = mean pulmonary artery pressure mRAP = mean right atrial pressure NT-proBNP = N-terminal pro-brain natriuretic peptide; PEA = pulmonary endarterectomy; TPR = total pulmonary resistance; WHO = World Health Organization. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY Jaïs X, D’Armini AM, Jansa P et al. J Am Coll Cardiol 2008 Dec 16;52(25):2127-34

110. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY Jaïs X, D’Armini AM, Jansa P et al. J Am Coll Cardiol 2008 Dec 16;52(25):2127-34

111. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BENEFiT STUDY Jaïs X, D’Armini AM, Jansa P et al. J Am Coll Cardiol 2008 Dec 16;52(25):2127-34

112. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CHEST STUDY RATIONALE RIOCIGUAT Soluble guanylate-cyclase stimulator Ch ronic Thrombo e mbolic Pulmonary Hypertension sGC- S timulator T rial riociguat

116. CHEST STUDIES: THE PAVIA EXPERIENCE CHEST TOP 5 ENROLLING CENTERS