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Chronic Thromboembolic Pulmonary artery Hypertension


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Chronic Thromboembolic Pulmonary artery Hypertension

  1. 1. Chronic Thromboembolic PulmonaryArtery Hypertension(CTEPH) By- Dr Awadhesh Kr Sharma
  2. 2. The Truth about Chronic Thrombo-embolic PulmonaryArterial Hypertension (CTEPH) CTEPH is a deadly disease Insidious in onset Once symptomatic, progresses rapidly without treatment Medical therapies exist, but most tested in patients with advanced disease (NEJM Jan 27,2011 Page351-360)
  3. 3. CTEPHChronic thromboembolic pulmonary hypertension (CTEPH) is an important cause of pulmonary hypertension that is commonly considered to be the consequence of acute pulmonary embolic disease.Following an acute event, unresolved residual thrombus becomes organised and fibrosed, leading to ongoing obstruction to pulmonary blood flow.Untreated, this leads to progressive pulmonary hypertension, right ventricular dysfunction and death (Suntharalingam J. et al. Thorax 2007)
  4. 4. “Not a disease, but asyndrome in which thepressure in the pulmonarycirculation is raised.” Peacock, Pulmo Circ 2nd ed
  5. 5. DefinitionChronic thromboembolic pulmonary hypertension is defined as- mean pulmonary-artery pressure greater than 25 mm Hg that persists 6 months after pulmonary embolism is diagnosed (J Am Coll Cardiol 2009;54:Suppl:S43-S54.)Occurs in 2 to 4% of patients after acute pulmonary embolism. (Chest 2006;130:172-5)
  6. 6. Natural History of CTEPHHoneymoon period after acute PEUsually present in their 40sLater presents with dyspnea, hypoxemia & RV dysfunctionDeath usually due to RV failure Riedel M, Stanek V, Widimsky J, et al. Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest 1982;81:151–8.
  7. 7. mPAP>50 mean survival 6.8 yrsFibrinolysis in acute PE shown to reduce the frequency of CTEPH.Most of CTEPH pts. even on anticoagulants will progress to Rt heart failure and death untreated (Kline J et al,Chest 2009;136:1202-10)
  8. 8. Incidence 0.5% to 3.8% of pts after an acute PE & in upto 10% of those with a history of recurrent PE will develop CTEPH. A prospective follow-up study of 78 survivors of acute pulmonary embolism, Four patients (5.1%) developed definite CTEPH, and 3 of these subsequently underwent successful PEA. (Ribeiro A, Lindmarker P, Johnsson H, Juhlin-Dannfelt A, Jorfeldt L. Pulmonary embolism: one-year follow-up with echocardiography Doppler and five-year survival analysis. Circulation. 1999;99:1325– 1330.) The only identifiable risk factors for persistent pulmonary hypertension were an age 70 years and a systolic pulmonary artery pressure 50 mm Hg at the initial presentation. In another prospective follow-up study of 223 patients who presented with acute pulmonary embolism, the incidence of symptomatic CTEPH was 3.1% at 1 year and 3.8% at 2 years (Pengo V, Lensing AW, Prins MH, Marchiori A, Davidson BL, Tiozzo F,Albanese P, Biasiolo A, Pegoraro C, Iliceto S, Prandoni P. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257–2264. )
  9. 9. Risk factors for CTEPH
  10. 10. VTE Risk factorsHypercoagulability Malignancy Nonmalignant thrombophilia Pregnancy Postpartum status (<4wk) Estrogen/ OCP’s Genetic mutations (Factor V Leiden, Protein C & S deficiency, Factor VIII, Prothrombin mutations, anti-thrombin III deficiency)Venous Statis Bedrest > 24 hr Recent cast or external fixator Long-distance travel or prolong automobile travelVenous Injury Recent surgery requiring endotracheal intubation Recent trauma (especially the lower extremities and pelvis)
  11. 11. VTE Risk factorsSpecific to women: Obesity BMI ≥ 29 Pregnancy Hypertension Heavy smoking (> 25cigs/day) Hormone replacement therapy OCP’s 10-30/100,000 users vs. 4-8/100,000 non-users.
  12. 12. While the hypercoagulable state has been clearly associated with the development of CTEPH, not all of the aforementioned factors have been clearly linked with CTEPH.Plasma VIII elevated in 41% of pts of CTEPH.Lupus anticoagulant 10% of CTEPHAnticardiolipin antibody in 20% CTEPHProtein C,S & antithrombin deficiencies <1% of pts with CTEPH.
  13. 13. Factors specific to pulmonary embolismRecurrent or unprovoked pulmonary embolismLarge perfusion defects when pulmonary embolism detectedYoung or old age when pulmonary embolism detectedPulmonary-artery systolic pressure >50 mm Hg at initial manifestation of pulmonary embolism
  14. 14. Chronic medical conditionsInfected surgical cardiac shunts or pacemaker or defibrillator leadsPost-splenectomyChronic inflammatory disordersCancer
  15. 15. Thrombotic factorsLupus anticoagulant or antiphospholipid antibodiesIncreased levels of factor VIIIDysfibrinogenemia
  16. 16. Genetic factorsABO blood groups other than OHLA polymorphismsAbnormal endogenous fibrinolysis
  17. 17. CTEPH: ASSOCIATIONS  Non O blood type CTEPH vs PAH ( 88% vs. 56%)  Lp (a) CTEPH vs. PAH vs. Control ( 26.6 mg/dl, 9.6 mg/dl, 7.2 mg/dl)† Bonderman D, et al. High prevalence of elevated clotting factor VIII in chronicthromboembolic pulmonary hypertension. Thromb Haemost 2003;90:372–376.‡ Ignatescu M, et al. Plasma Lp(a) levels are increased in patients with chronicthromboembolic pulmonary hypertension. Thromb Haemost 1998;80:231–232.
  18. 18. SPLENECTOMY AS A RISK FACTOR FOR CTEPH Prevalence of Splenectomy in CTEPH is significantly higher than in IPAP and control. Mean interval from S/p Splenecotmy  CTEPH onset: 16 +_ 9 yrs Retrospective Chart Review of 257 pt referred for CTEPH over 10 yrs vs. IPAH vs. other pulm diseases. in CTEPH – 8.6% ( CI 95%, [5.2-12.0%]) had splenectomy vs. 2.5% ( CI 95%, [ 0.7-4.4%]) IPAP and 0.56% ( CI 95%,[0-1.6%]) in other pulm diseases † Again most Splenectomy – distal CTEPH, not PEA candidates.Jais X, et al Splenectomy and chronic thromboembolic pulmonary hypertension. Thorax2005;60:1031–1034
  19. 19. PathophysiologySmall vessel arteriopathy- - medial hypertrophy - intimal proliferation - microvascular thrombosis - plexiform lesion formation Persistent macrovascular obstruction Vasoconstriction Neurohumoral factors -endothelin 1- potent vasoconstrictiors/triggers of microvascular changes. (Reesink HJ et al,Circ J 2005;70:1058-63)
  20. 20. Progression of CTEPH Acute or recurrent PTE in pulmonary arteries Organisation these thrombi Occurence in situ thrombus due to slow blood flow in obstructed pulmonary arteries Occurence of arteritis in non obstructed small distal pulmonary arteries(remodelling) Increased PVR, pulmonary hypertension CTEPH
  21. 21. Histopathological paradoxTissues/vessels distal to occluded segment- normalDistal vessel distal to patent pulmonary arterial segments- small vessel abnormalities Arrows – not perfused due obstruction by clots. ( normal vessels downstream) RUL get all the flow of R lung – remodeling on Bx Moser,Braunwald et al,Chest 1973;64:29- 35
  22. 22. Chronic thromboembolic pulmonary hypertension (CTEPH) Clinical presentation -  The diagnosis of CTEPH is usually not made until the degree of pulmonary hypertension is advanced  A patient may carry on relatively normal activities following a pulmonary embolic event, whether clinically apparent or occult, even when extensive pulmonary vascular occlusion has occurred (asymptomatic –honeymoon – period) Fedullo PF et al.N Engl J Med 2001
  23. 23. Chronic thromboembolic pulmonary hypertension (CTEPH) Clinical presentation -  Patients who have CTEPH typically complain of exertional dyspnea and a gradual decrease in exercise tolerance over months to years  Diagnostic delay :  Nonspesific nature of symptoms  Absence of a history of prior acute symptomatic venous thromboembolism (DVT / PE)  The average delay from the onset of cardiopulmonary symptoms to establisment of the correct diagnosis can range from 2 to 3 years Fedullo PF et al.Semin Resp Crit Care Med 2003 Auger WR et al. Clin Chest Med 2007
  24. 24. Chronic thromboembolic pulmonary hypertension (CTEPH) Clinical presentation - Progressive dyspnea and exercise intolerance due to CTEPH are often erroneously attributed to ;  coronary artery disease  cardiomyopathy  congestive heart failure  interstitial lung disease  COPD (mild)  asthma  physical deconditioning  psychogenic dyspnea Prior to consideration of a pulmonary vascular problem as a basis for their complaints, many patients with CTEPH have undergone ;  left-sided cardiac catheterizations (one or more )  coronary angiograms  lung biopsy.  enrolling in an exercise program  seeking psychiatric help. Fedullo PF et al.N Engl J Med 2001 Auger WR et al. Clin Chest Med 2007
  25. 25. Chronic thromboembolic pulmonary hypertension (CTEPH) Clinical presentation Symptoms  Progressive dyspnea  Nonproductive cough (especially with exertion)  Hemoptysis  Palpitations  A change voice quality or hoarseness  Exertional chest pain  Near-syncope or syncope  Lower extremity edema Fedullo PF et al.Semin Resp Crit Care Med 2003 Auger WR et al. Clin Chest Med 2007
  26. 26. Chronic thromboembolic pulmonary hypertension (CTEPH) Clinical presentation Physical examination - May be subtle early in the course of the illness. In time obvious findings develop, which may include :  Right ventricular lift  Jugular venous distension  Prominent A and V wave venous pulsations  Fixed splitting of S2 with an accentuated pulmonic component  A right ventricular S4 gallop  A tricuspid regurgitation murmur  Hepatomegaly  Ascites  Peripheral edema, which may be a result of either chronic lower extremity venous outflow obstruction or right ventricular failure. Fedullo PF et al.N Engl J Med 2001 Auger WR et al. Clin Chest Med 2007
  27. 27. Chronic thromboembolic pulmonary hypertension (CTEPH)Clinical presentation Physical examination - The presence of flow murmurs over the lung fields(30 percent of patients).  turbulent flow through partially obstructed or recanalized pulmonary arteries  high pitched and blowing in quality  heard over the lung fields rather than the precordium, accentuated during inspiration  frequently heard only during periods of breath-holding  they have not been described in primary pulmonary hypertension, which represents the most common competing diagnostic possibility Fedullo PF et al.N Engl J Med 2001 Auger WR et al. Clin Chest Med 2007
  28. 28. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Pulmonary function tests  Useful for excluding coexisting parenchymal lung disease or airflow obstruction  Often within normal limits  The majority of patients with CTEPH have a reduction in the single breath diffusing capacity for carbon monoxide (DLCO); a normal value, however, does not exclude the diagnosis  Approximately 20 percent of patients demonstrate a mild to moderate restrictive defect  A mild obstructive defect may be present as a result of mucosal hyperemia, which is related to development of a large bronchial arterial collateral circulation Steenhuis KS. Et al. Eur Respir J 2000 Auger WR et al. Clin Chest Med 2007
  29. 29. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Blood gas analysis  Resting arterial PO2 may be within normal limits  Hypoxemia at rest implies very severe right ventricular disfunction or the presence of a right -to- left shunt, as through a patent foramen ovale  Majority of patients have a decline in the arterial PO2 with exercise  The alveolar-arterial oxygen gradient is typically widened  Dead space ventilation (VD/VT) is often increased at rest and worsens with exercise  Minute ventilation is typically elevated as a result of the increased dead space ventilation. Fedullo PF et al. N Engl J Med 2001 Auger WR et al. Clin Chest Med 2007
  30. 30. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Chest radiography  Often normal  Enlargement of both main pulmonary arteries or asymmetry in the size of the central pulmonary arteries  Areas of hypoperfusion or hyperperfusion  Evidence of old pleural disease, unilaterally or bilaterally  Right atrial or right ventricular enlargement, based on the outline of the right cardiac border ( especially on the lateral film by encroachment on the normally empty retrosternal space)  Cardiomegaly Eur Radiol 2007;17:11-21
  31. 31. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Electrocardiography (ECG)  Right axis deviation  Right ventricular hypertrophy  Right atrial enlargement  Right bundle – branch block  ST segment displacement  T- wave inversions in anterior precordial and inferior limb leads Auger WR et al. Clin Chest Med 2007
  32. 32. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Echocardiography Enlargement and reduced systolic function of the right ventricle are usually apparent, Leftward septal displacement can impair left ventricular filling and performance ECHO is useful for the excluding;  Left ventricular dysfunction  Valvular disease  Cardiac malformations Sensitive but not specific Menzel T et al. Chest 2000 Auger WR et al. Clin Chest Med 2007
  33. 33. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Radioisotopic V / Q scanning –  In chronic thromboembolic disease, at least one (and more commonly, several) segmental or larger mismatched ventilation- perfusion defects are present but not spesific for this condition  In idiopathic pulmonary arterial hypertension (IPAH) , perfusion scans are either normal or exhibit a "mottled" appearance characterized by subsegmental defects  V- scannig of the lungs is almost always normal J Nuclear Med 2007;48:680-4
  34. 34. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Radioisotopic V / Q scanning – Conditions indistinguishable from CTEPH in V/Q appearance :  Extrinsic vascular compression from mediastinal adenopathy or fibrosis  Primary pulmonary vascular tumors ( ie. Angiosarcoma )  Pulmonary veno-occlusive disease  Large-vessel pulmonary arteritis Additional imaging studies are needed to define the vascular abnormality and establish the diagnosis  Cannot localize the extent of the disease  Cannot determine surgical accessibility Hasegawa I et al. AJR 2004 Fedullo PF et al. N Engl J Med 2001
  35. 35. (CTEPH)Diagnosis Computed tomogaphy (CT) CT findings in CTEPH : Right atrial and ventricular enlargement Chronic thromboembolic material within dilated central pulmonary arteries Central pulmonary artery enlargement Variations in the size of lobar and segmental- level vessels Mosaic perfusion of the lung parenchyma Peripheral, scar- like densities in hypo- attenued lung regions Presence of mediastinal collateral vessels arising from the systemic arterial circulation (Eur J Radiol 2009;71:49-54)
  36. 36. Diagnosis Computed tomogaphy (CT) -CT imaging is also valuable in : Assesment of the lung parenchyma in patients who have coexisting emphysematous or restrictive lung disease Detection mediastinal pathology that might account for occlusion of the central pulmonary arteries
  37. 37. CTACT angiography efficacy graeter in the main & lobar pulmonary arteriesCTA efficacy decreases in the segmental & subsegmental vessels. (Eur Radiol 2009;71:49-54)
  38. 38. M R AngiographyLimited sensitivityNo extra advantage over CTA (Ann Med Intern2010;1 52:434-43)
  39. 39. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Pulmonary angiography Pouch defects Pulmonary artery webs or bands Intimal irregularities Abrupt narrowing of the major pulmonary arteries Obstruction of lobar or segmental vessels at their point of origin, with complete absence of blood flow to pulmonary segments normally perfused by those vessels Fedullo PF et al. N Engl J Med 2001
  40. 40. Chronic thromboembolic pulmonary hypertension (CTEPH)Diagnosis Cardiac catheterization Defines the severity of the pulmonary hypertension and degree of cardiac dysfunction Biplane imaging provides optimal anatomical detail When dilated and overlapping vessels are present, the lateral view provides more detailed images of lobar and segmental anatomy than those obtained with an anterior–posterior view alone Fedullo PF et al. N Engl J Med 2001 Auger WR et al. Clin Chest Med 2007
  41. 41. (CTEPH)Diagnosis Pulmonary angioscopyA diagnostic fiberoptic device, was developed specifically for preoperativeevaluation.The angioscopic features of organized, chronic emboli :  Roughening or pitting of the intimal surface,  Bands and webs traversing the vascular lumen,  Pitted masses of chronic embolic material within the lumen,  Partial recanalization.  Intimal plaques are a nonspecific finding in pulmonary hypertension of any cause.  Angioscopy is performed in approximately 30 percent of patients undergoing evaluation for thromboendarterectomy Fedullo PF et al. N Engl J Med 2001
  42. 42. (NEJM Jan 27,2011 Page351-360)
  43. 43. Proposed algorithm for the diagnostic approach to patients with CTEPH. Ventilation-perfusionscanning is the recommended screening procedure because a normal perfusion scan virtually rules out CTEPH. When perfusion scans show indeterminate results... Hoeper M M et al. Circulation 2006;113:2011-2020Copyright © American Heart Association
  44. 44. Treatment of CTEPH
  45. 45. Proposed Treatment approach Hoeper M et al, Chronic Thromboembolic Pulmonary Hypertension, Circulation 2006; 113; 2011 - 2020
  46. 46. Pulmonary thromboendarterectomy The most effective therapy –- Pulmonary thromboendarterectomy. (J Am Coll Cardiol 2009;54:Suppl:S67-S77.) Improvement in hemodynamics after pulmonary thrombo-endarterectomy causes - Reverse right ventricular remodeling The beneficial effect usually persists, unless small-vessel arteriopathy or recurrent pulmonary embolism develops. (Long-term outcome after pulmonary endarterectomy. Am J Respir Crit Care Med 2008;178:419-24.)
  47. 47. Pulmonary thromboendarterectomy is considered in symptomatic patients who have hemodynamic or ventilatory impairment at rest or with exercise.The mean pulmonary vascular resistance in patients undergoing surgery is 800 to 1000 dyn·sec·cm.Thromboendarterectomy is also considered in patients who have normal or nearly normal pulmonary hemodynamics at rest but in whom marked pulmonary hypertension develops during exercise.
  48. 48. Pulmonary endarterectomy is performed during circulatory arrest, removing obstructive material from each pulmonary artery, and its lobar and segmental branches, (20–30 branches in total), and is the only way to reduce pulmonary vascular resistance by at least 50%.The operation is performed entirely through a median sternotomy and through the pericardium without having to open the pleura or to dissect the pulmonary artery outside the pericardium. Circulation. 2006;113:2011-2020
  49. 49. It is interesting to note that the mortality rate from this operation is closely related to the haemodynamic severity. For pulmonary resistance 900 dynes/s/cm-5, the mortality rate was 4%, and increased to 10% in patients with resistance between 900–1,200 dynes/s/cm-5, and to 20% for higher resistance.For the last 40 patients of the series,the authors excluded operating on patients with the very distal form of thomboembolism associated with severe haemodynamic alterations, and the mortality rate dropped to 5%. Circulation. 2006;113:2011-2020
  50. 50. Obstructed lumen Patent lumen Aspirating> dissectorThromboembolicmaterial being removedwith forceps Circulation. 2006;113:2011-2020
  51. 51. The only absolute contraindication to thromboendarterectomy is the presence of severe underlying lung disease, either obstructive or restrictiveAdvanced age, severe right ventricular failure, and the presence of collateral disease influence the risk assessment but are not absolute contraindications.Placement of a filter in the inferior vena cava is recommended before surgery in all pts except those with a clearly defined source of emboli other than the deep veins in the legs.
  52. 52.  Preoperative predictors of favorable outcomes include 1- A pulmonary vascular resistance of less than 1200 dyn • sec • cm−5 2- The absence of major coexisting conditions. Patients in whom the postoperative pulmonary vascular resistance decreases by at least 50%, to a value of less than 500 dyn • sec • cm−5, have a more favorable. (Circulation 2007;115:2153-8.)
  53. 53. Pulmonary EndarterectomyChance of cure in proximal obstruction driven Pulmonary Hypertension onlySurgical classificationGroup1: fresh thrombus in main lobarGroup 2: intimal thickening prox. to segmental arteriesGroup 3: within distal segmental arteriesGroup 4: distal vasculopathy w/o visible thromboembolic ds.Group 1 & 2 - most favorable outcome. (J Thorac Cardiovasc Surg 2007;133:58- 64.)
  54. 54. Early diagnosis and PEA early can decrease small vessel contribution to PVR i.e and make a patient better PEA candidateMedical bridge to PEA with vasodilators in pts. with high Pre –Op PVR who otherwise are good PEA candidate .
  55. 55. Proposed way to determine if PEA will lower PVRRt heart cath with Pulm. Artery Occlusion technique: - based on assumption of decay PAOP waveform. - PVR may be partitioned to large arterial ( upstream) and small arterial + venous ( downstream).
  56. 56. Sample pulmonary artery pressure occlusion waveforms from 2 patients with (A) primarilyupstream resistance (note the relatively rapid drop in pressure to Ppao) and (B) significantdownstream resistance (longer time is needed for the pressure to reach Ppao)
  57. 57. N Eng J Med,2011, V ol 345, No 20
  58. 58. The 30-day mortality ranges from less than 5% in the most experienced centers to 10% in general.The two most common anticipated postoperative sequelae are – 1-The pulmonary-artery steal syndrome 2-Reperfusion pulmonary edema (J Thorac Cardiovasc Surg 2007;133:58-64.)
  59. 59. EXPERIENCE AND RESULTS WITH PULMONARY THROMBOENDARTERECTOMY-A SINGLE INSTITUTIONEXPERIENCE INTHE INDIAN SUBCONTINENTChattuparambil B, Shetty D P, Cherian G, Murali Mohan BV, Karthik GA, Punnen JNarayana Hrudayalaya Institute of Cardiac Sciences, No. 258/A, Bommasandra IndustrialArea, Anekal Taluk, Bangalore, India .PIN-560099 Between June 2004 and December 2010 209 patients referred to our institute with CTEPH underwent Pulmonary Thrombo Endarterectomy. The diagnosis was based on 64-slice CT Pulmonary Angiography. The data was analysed retrospectively.
  60. 60. RESULTS209 patients in the 15-69 year age group underwent PTE between June 2004 andDecember 2010. The male: female ratio was 1.5:1.2 ,5 patients had CTEPH, 4 had acutepulmonary embolism with unstable hemodynamics and failure of thrombolysis. Twopatients underwent redo PTE. 154 cases were isolated PTE while 55 were combinedprocedures. 47.8% (100/209) had proven deep venous thrombosis .The overall mortalityfor the procedure was 12.9% (27/209). The causes of mortality were persistent pulmonaryarterial hypertension in 66.6% (18/27), reperfusion edema in 22.2 % (6/27) andmechanical injury in 11.1%(3/27).The pulmonary arterial pressure regressed to <40 mmHg in 71.7% (150/209) .The mean duration of ICU stay was 6 days (3-50).The meanduration of ventilatory support was 3.3 days (1-19).15 patients required ExtracorporealMembrane Oxygenation (ECMO) support for varied reasons. Of these, there were twosurvivors. The mean duration of hospital stay was 13 days (9-60). Two patients died outof hospital, one of recurrent pulmonary embolism following discontinuation ofanticoagulation and one of persistent pulmonary arterial hypertension.180 patients arestill on regular follow up, and 30 of them have persistent pulmonary hypertension withNYHA class I-III symptoms. The rest are doing extremely well with good quality of life.
  61. 61. Balloon Pulmonary-Artery Angioplasty  Balloon pulmonary-artery angioplasty is an alternative therapy in selected patients who have inoperable disease due to distal surgically inaccessible disease or persistent or recurrent pulmonary hypertension after thromboendarterectomy.  Successful balloon pulmonary angioplasty may reduce pulmonary- artery pressure in patients with chronic thromboembolic pulmonary hypertension  However, experience with this procedure is very limited, and it is rarely performedMasaharu Kataoka, MDCIRCINTERVENTIONS.112.971390 Published online before print November 6, 2012
  62. 62. Balloon Pulmonary Angioplasty for Treatment of Chronic Thromboembolic Pulmonary HypertensionJeffrey A. Feinstein, MD, MPH; Samuel Z. Goldhaber, MD; James E. Lock, MD;Susan M. Ferndandes, PA-C; Michael JLandzberg, MDBackground—Although pulmonary thromboendarterectomy is increasingly successful for the definitive treatment of chronic thromboembolic pulmonary hypertension (CTEPH), not all patients have surgically accessible disease. Others are poor surgical candidates because of comorbid illness. Therefore, for selected patients, we defined and implemented an alternative interventional strategy of balloon pulmonary angioplasty (BPA).Methods and Results—Eighteen patients (mean age, 51.8 years; range, 14 to 75 years) with CTEPH underwent BPA; they averaged 2.6 procedures (range, 1 to 5) and 6 dilations (range, 1 to 12). Selection of pulmonary artery segments fordilation required (1) complete occlusion, (2) filling defects, or (3) signs of intravascular webs. After an average of 36months of follow-up (range, 0.5 to 66 months), the average New York Heart Association class improved from 3.3 to1.8 (P,0.001), and 6-minute walking distances increased from 209 to 497 yards (P,0.0001). Pulmonary artery meanpressures decreased from 43.0612.1 to 33.7610.2 mm Hg (P50.007). Eleven patients developed reperfusionpulmonary edema; 3 required mechanical ventilation.Conclusions—BPA reduces pulmonary artery hypertension in patients with CTEPH and is associated with long- term improvement in New York Heart Association class and 6-minute walking distances. BPA is a promising interventional technique that warrants randomized comparison with medical therapy in CTEPH patients who are not surgical candidates. (Circulation. 2001;103:10-13.)Key Words: balloon n angioplasty n embolism n thrombus n pulmonary heart disease
  63. 63. Pulmonary transplantation The lungs, in contrast to other transplantable organs, are in contact with the external milieu through the tracheobronchial tree and are at risk of pneumonia during donor resuscitation. Recipient selection criteria1. age <55 yrs;2. absence of mechanical respiratory insufficiency due to scoliosis;3. absence of phrenic paralysis4. absence of recent neoplastic disease or other potentially life- threatening diseases.
  64. 64. Indications for transplant Patients with a life expectancy of <1 yr,consistent with a functional status of NYHA stage III orIV. Recent worsening of dyspnoea and haemodynamic parameters, such as a right atrial pressure of >12 mmHg, pulmonary arterial pressure >60 mmHg, a cardiac index <2.2 L/min-1/m-2 or indexed pulmonary resistance >30 U
  65. 65. Lung transplant for CTEPHHeart and lung, b/l lungs, single lungHeart lung best  less bronchial ischemia, heart already adapted to pulm. CirculationAn advantage of bilateral lung transplantation is that the donor heart can be transplanted into another recipient awaiting heart transplantation aloneTrue to all: life long immune supression, rejections ( acute, chronic), susceptibility to viral, fungal infections) Eur Respir J 2004; 23: 637–648.
  66. 66. In the series of 101 pulmonary transplants performed for pulmonary hypertension at the Marie- Lannelongue Hospital between 1986–2002, 18 were for CTEPH. There were 70 heart-lung, 28 bilateral and only three single lung transplants. The perioperative mortality was y20% and was not significantly different between the operation performed Eur Respir J 2004; 23: 637–648.
  67. 67. Eur Respir J 2004; 23: 637–648.
  68. 68. Medical TherapyAnticoagulation is prescribed in most patients with chronic thromboembolic pulmonary hypertension.Among patients with unprovoked or idiopathic pulmonary embolism, an indefinite duration of anticoagulation has reduced the risk of recurrent venous thromboembolism & CTEPH. (Comparison of low-intensity warfarin therapy with conventional-intensity warfarin therapy for long-term prevention of recurrent venous thromboembolism. N Engl J Med 2003;349:631-9.)
  69. 69. About 50% CTEPH rejected for PEAPt. w/ high PVR mainly d/t small vessels – poor surgical candidates. Traditional therapies:  Anticoagulants, diuretics, digitalis, oxygen Agreement on Anticoagulation to in situ thrombosis ( goal INR 2-3)  Diuretics for volume overload in R CHF. Novel Therapies  Prostacyclin analogues,  Endothelin receptor blocker  PDE 5 inhibitor
  70. 70.  Situations for medical RX in CTEPH  1) can’t do PEA ( too much distal or small vessel dz) or not a candidate for other reasons.  2) can do PEA, but PVR too risky high or PEA is far away  bridge to PEA.  3) post PEA still w/ symptoms and PVR high
  71. 71. Prostacyclin agonistPowerfull systemic & pulmonary vasodilatorPlatelet aggregation inhibitorAntiproliferativeCytoprotectiveFibrinolytic
  72. 72. Epoprostenol- - short half life of 3 min - continuous iv infusion through tunnelized catheter - started at 1ng/kg/min & gradually increased toby 1 ng/kg/min every 12 hr upto 10 ng/kg/min - side effects are jaw pain,headache,diarrheas,flushes,lower limb pain,nausea,vomitting (Robbins et al 1998,chest 114:1269-1275)
  73. 73.  Treprostinil - S/C administration - 22.5 ng/kg/min(Results based on TRIUMPH study)ILLOPROST - By inhalation - six to nine inhalation a day for at least 30 min - Iloprost is given by 2.5- or 5.0-µg ampules via a dedicated nebulizer (Olschewski et al ,2002)Beraprost - oral - significant improvement on the 6 MWD in IPAH in double blind study conducted by Galie et al .2002,NEJM 353:2148-2157.
  74. 74. Epoprostenol Bressler P. et al evaluated bridging x 6 wks pre PEA ( n=6) w severe CTEPH ( PVR>1200). Result: mean reduction in PVR of 28% ( median 33%). Post PEA  improved CI, mPAP and TPRP. Bresser et al Continuous intravenous epoprostenol for chronic thromboembolic pulmonary hypertension Eur Respir J 2004; 23:595 - 600
  75. 75. Endothelin receptors antagonist Powerful vasoconstrictor(ET-A receptors) Promoter of smooth muscle cell proliferation(ET-B receptors) Dual ET-1 receptors antagonist Bosentan-(2008 International PHA Conference and Scientific Sessions) - side effects systemic vasodilation and hepatic dysfunction - The approved dosage of bosentan is 125 mg twice dailySelective ET-A receptor antagonists- Sitaxsentan – 100mg daily dose - 65 m increase in 6MWD (Barst et al.2002) - once daily at a 100 mg dose Ambrisentan- once daily at a 5-mg dose Eur Respir J 2012; 20: 203 - 400
  76. 76. PDE 5 inhibitiors Sildenafil (The recommended dosage is 20 mg three times daily, but dosages as high as 80 mg three times daily have been used safely ) Tadalafil (The effective dose was 40 mg once daily.) Vardenafil Stabilizes c GMP and NO; potent pulmonary vasodilator.J Heart Lung Transplant. 2010 Jun;29(6):610-5(Chronic thromboembolic and pulmonary arterial hypertension share acutevasoreactivity properties. Chest 2006;130:841-6.)
  77. 77. Nonoperable distal progressive CTEPH ( mPAP= 52, PVRI 1,935) On cath pt. had vasodilator reactivity to inhaled nitric oxide. Results: after 6 month 6MWD and PVR improved.Ghofrani et. al; Sildenafil for long –term treatment of non – operable chronic thromboembolic pulmonaryhypertension. Am J Resp Crit Care Med 2003; 167: 1139 - 1141
  78. 78. Calcium channel blockers- vasodilator - Nifedipine 90-240 mg/day or dilitiazem 360-900 mg/day - effective in pts having positive response to acute testing with vasodilators - only 12.6% of pts could be treated by CCB (Based on studies by Rich et al & Sitbon et al study on 557 pts in 1998 published in Eur Respir J 2:265-270)
  79. 79. Role of IVC filters in CTEPH  sparse evidence in CTEPH  F/u study (n=18) IVC Filter to prevent recurrence PE long term as well as high risk periop period.*  IVC Filters + A/C  reoperation in post PEA** Experts disagree on utility of IVC, slightly more agreement on periop IVC Filter placement for PEA.*Hajduk et al, implantation of LGM inferior vena Cava Filters in patients with Chronic Pulmonary Hypertensionduring a course of major vessel Thromboembolism: observation of 18 patient ( in polish). Pneumonol Alergol Pol1996; 64:154 – 160**Mo M et al, Reoperative pulmonary Thromboendarterectomy. Ann Thorac Surg 1999; 68 : 1770 - 1776
  80. 80. Potential future therapiesTyrosine kinase inhibitors - PDGF inhibitors - causes regression of pulmonary vascular remodellingRho Kinase inhibitors - causes vasodilation & prevents vascular remodeling - Fasudil ( Fagan et al 2010,Am J Physiol Lung Cell Mol Physiol 287:L 656-664)Statins- - enhances bone morphogenetic receptor II ( BMPR-II) ( Hu et al 2006,Biochem Biophys Res Commun 339:59-64)Vasoactive Intestinal Peptide- - potent bronchodilator - systemic & pulmonary vasodilator - via inhalation (Said et al 2007,circulation 115:1260-1268)
  81. 81. SSRI - Protective effects on occurrence of PAH in animal modelAdrenomedullin- - vasodilator peptide - smooth muscle cell proliferator inhibitor - iv/inhalation ( Nagaya et al 2004,circulation 109:351-356)
  82. 82. Guanylate cyclase (sGC) stimulatorData from the Phase 3 CHEST-1 trial (Chronic Thromboembolic Pulmonary Hypertension sGC- Stimulator Trial)261 patients were randomized and treated with either riociguat or placeboRiociguat also showed statistically significant improvements in select secondary endpoints, including pulmonary vascular resistance (PVR) (P<0.0001), N- terminal prohormone brain natriuretic peptide (NT- proBNP) (P<0.0001) and WHO functional class (FC) (P=0.0026).
  83. 83. Recommendations for chronicthromboembolic pulmonary hypertensionStatement Class LevelThe diagnosis of CTEPH is based on the presence I Cof pre-capillary PH (mean PAP 25 mmHg,PWP 15 mmHg, PVR .2 Wood units) inpatients with multiple chronic/organizedocclusive thrombi/emboli in the elasticpulmonary arteries (main, lobar, segmental,subsegmental)In patients with CTEPH lifelong anticoagulation is I CindicatedSurgical pulmonary endarterectomy is the I Crecommended treatment for patients withCTEPH European Heart Journal (2009) 30, 2493– 2537
  84. 84. Statement Class LevelOnce perfusion scanning and/or CT angiography IIa Cshow signs compatible with CTEPH, the patientshould be referred to a centre with expertise insurgical pulmonary endarterectomyThe selection of patients for surgery should be IIa Cbased on the extent and location of theorganized thrombi, on the degree of PH, and onthe presence of co-morbiditiesPAH-specific drug therapy may be indicated in IIb Cselected CTEPH patients such as patients notcandidates for surgery or patients with residualPH after pulmonary endarterectomy European Heart Journal (2009) 30, 2493– 2537
  85. 85. In patients with operable CTEPH, PTE is the treatment of choice for improved hemodynamics functional status, and survival. Level of evidence: low; benefit: substantial; grade of recommendation: B.In patients with CTEPH deemed inoperable or with significant residual postoperative PH, balloon dilation, PAH medical therapy, or LT may be considered. Level of evidence: low; benefit: small/weak; grade of recommendation: C. Pulmonary Arterial Hypertension: ACCP Guidelines 2007
  86. 86. Indian perspectiveFirst heart-lung transplant in India in 1999 in Madras medical mission 2 more patients underwent transplant afterthatinitial experience is encouraging
  87. 87. Apixaban for Extended Treatment of VenousThromboembolismBackgroundApixaban, an oral factor Xa inhibitor that can be administered in a simple, fixed-dose regimen, may be an option for the extended treatment of venous thromboembolism.MethodsPatients with venous thromboembolism who had completed 6-12 months of anticoagulation therapy were randomized to apixaban 2.5 mg twice daily (n = 840), apixaban 5 mg twice daily (n = 813), versus placebo twice daily (n = 829). Study drugs were administered for 12 months. N Engl J Med 2012;Dec 8
  88. 88. Interpretation:Among patients with venous thromboembolism who had completed 6-12 months of anticoagulation therapy, extended therapy with apixaban (2.5 mg or 5 mg twice daily) reduced symptomatic recurrent venous thromboembolism or death. Clinical benefit was accomplished without an increase in major bleeding; however, clinically relevant nonmajor bleeding was increased with apixaban 5 mg compared with placebo N Engl J Med 2012;Dec 8
  89. 89. ASPIRE Trial design: Patients who had a first episode of unprovoked venous thromboembolism and completed initial anticoagulation therapy were randomized to aspirin 100 mg daily (n = 411) vs. placebo daily (n = 411). Results (p = 0.09)  Recurrent venous thromboembolism at 37 months: 14% with aspirin vs. 18% with placebo 18 (p = 0.09)  The following events are reported per year for% 14 aspirin vs. placebo:  Major vascular event: 5.2% vs. 8.0% (p = 0.01)  Major bleeding and clinically relevant nonmajor bleeding: 1.1% vs. 0.6% (p = 0.22)  Major vascular event, major bleeding, or all- cause mortality: 6.0% vs. 9.0% (p = 0.01) Conclusions • Among patients with unprovoked first venous thromboembolism who completed initial anticoagulation therapy, the use of aspirin failed Aspirin Placebo to reduce the primary outcome of recurrent venous thromboembolism Brighton TA, et al. N Engl J Med 2012;Nov 4:[Epub]
  90. 90. Conclusions Chronic thromboembolic pulmonary hypertension (CTEPH) is an important complication of acute VTE The average delay from the onset of symptoms to establisment of the correct diagnosis can range from 2 to 3 years 2D ECHO is an early & important laboratory method to determine the severity of the disease V/Q sscannig gives considerable clues in the diagnosing of CTEPH Right- heart catheterization should be considered in any patient with unexplained dyspnea and segmental or larger defects on V/Q perfusion scanning, especially if there is echocardiographic evidence of right atrial or right ventricular dysfunction