Residual Pulmonary Hypertension After Pulmonary Endarterectomy
2016; Lippincott Williams & Wilkins; Volume: 133; Issue: 18 Linguagem: Inglês
10.1161/circulationaha.116.022595
ISSN1524-4539
Autores Tópico(s)Cardiovascular Issues in Pregnancy
ResumoHomeCirculationVol. 133, No. 18Residual Pulmonary Hypertension After Pulmonary Endarterectomy Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBResidual Pulmonary Hypertension After Pulmonary EndarterectomyThe Fog Is Clearing Marius M. Hoeper, MD Marius M. HoeperMarius M. Hoeper From Department of Respiratory Medicine and German Center of Lung Research (DZL), Hannover Medical School, Hannover, Germany. Originally published6 Apr 2016https://doi.org/10.1161/CIRCULATIONAHA.116.022595Circulation. 2016;133:1731–1733Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: May 3, 2016: Previous Version 1 Surgical pulmonary endarterectomy (PEA) is unanimously considered the preferred treatment for chronic thromboembolic pulmonary hypertension (CTEPH),1–4 even though there has never been a randomized, controlled study evaluating the safety and efficacy of this approach. This is readily explained by the fact that CTEPH is often a rapidly fatal disease if left untreated.5,6 PEA was developed in the early seventies of the past century,7 and it remained the only treatment for CTEPH for nearly 40 years. In several countries, centers of expertise emerged and the results of surgery improved constantly. At the University of California, San Diego, the postoperative mortality in the first 143 patients who underwent PEA surgery between 1970 and 1998 was 16.8%.8 This figure dropped to 2.2% in the 500 patients operated on between October 2006 and December 2010.8Article, see p 1761Although information on postoperative mortality of PEA surgery was readily available, the picture was somewhat foggy when it came to postoperative morbidity. Most patients had substantial hemodynamic and functional improvements after surgery, but systematic long-term follow-up data were scarce. Although PEA was considered a curative approach, it was noted early on that some patients had residual or recurrent pulmonary hypertension after surgery.9 However, given the lack of systematic and coordinated follow-up strategies, the incidence and clinical relevance of residual pulmonary hypertension remained largely unknown. There was not even a uniform definition of residual pulmonary hypertension after surgery. Research groups looking at the postoperative course after PEA have used mean pulmonary artery pressure (PAPm) thresholds of 25 to 30 mm Hg and pulmonary vascular resistance thresholds of 400 to 500 dynes·s·cm−5,10–13 although PAPm≥25 mm Hg at rest is the globally accepted definition of pulmonary hypertension, and a threshold of 240 dynes·s·cm−5 defines an elevated pulmonary vascular resistance in patients with pulmonary arterial hypertension.14Against this background, the clinical research article by Cannon and coworkers15 in this issue of Circulation fills important gaps of knowledge. This article comes from 8 designated pulmonary hypertension centers in the United Kingdom and Ireland. Only these centers are allowed to prescribe medications for pulmonary hypertension in their respective countries. All surgical PEAs are performed at Papworth Hospital, Cambridge. For the first year after surgery, the patients are followed at Papworth Hospital, after which they are transferred back to the referring pulmonary hypertension centers. This setting allows for a complete long-term follow-up of patients who undergo surgical treatment of CTEPH. The authors report on 800 consecutive patients who underwent PEA between 1997 and 2012 and who were systematically followed after surgery. The cumulative 30-day mortality after PEA was 13.2% for the first half of the cohort and 2.4% for the second half, closely reflecting the San Diego experience. The 3-year survival after surgery in the second half of the cohort was 90%; and 85% of the patients presented in functional class I or II. It is noteworthy that CTEPH was identified as the direct cause of death in only 35% of those who died during the long-term follow-up after surgery.Hemodynamic values were systematically obtained at day 1, month 3 to 6, and month 12 after surgery. It was noted that the hemodynamics at day 1 poorly predicted hemodynamics at the later time points, whereas the hemodynamics at month 3 to 6 and month 12 were tightly correlated. At month 3 to 6, a PAPm≥25 mm Hg was found in 51% of the patients. Hence, for the first time, there is convincing evidence indicating that about half of all patients undergoing PEA surgery have residual pulmonary hypertension.The next question is whether any degree of residual pulmonary hypertension is clinically relevant, or whether there is a hemodynamic threshold that is associated with clinical symptoms or a poorer survival, or both. In the study by Cannon and coworkers, PAPm≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s·cm−5 after surgery were the best hemodynamic predictors of death attributable to CTEPH. Still, the authors suggested that a postoperative PAPm≥30 mm Hg may be a more suitable threshold to define clinically relevant residual pulmonary hypertension. This hypothesis was mainly based on the notion that physicians were more likely to prescribe pulmonary vasodilators in patients with PAPm≥30 mm Hg. This line of thought is not without pitfalls, because the follow-up catheterization was not triggered by clinical symptoms, but it was performed as a standardized procedure. The presented data do not indicate whether patients with a PAPm between 30 mm Hg and 37 mm Hg were more symptomatic or had a higher likelihood of death than patients with lower PAPm. Simply seeing the results of the hemodynamic assessments may have triggered the decision to initiate pulmonary vasodilator therapy, because physicians may be reluctant to withhold such treatments in patients whom they consider to have significant residual pulmonary hypertension. This is comprehensible and probably reflects what many physicians would have done, but it does not prove the clinical relevance of the 30 mm Hg threshold. However, a careful assessment of the data by Cannon and coworkers shows that the long-term mortality risk may indeed start to increase with a postoperative PAPm≥30 mm Hg, and many physicians may be as reluctant as their colleagues from the United Kingdom and Ireland not to treat these patients. Hence, the authors are probably right when suggesting PAPm≥30 mm Hg as a useful threshold to define relevant residual pulmonary hypertension after PEA surgery. However, as they stated in their article, other factors such as symptoms and right ventricular performance are also important to determine the clinical relevance of residual pulmonary hypertension.Despite the remaining uncertainties, these data help physicians to make treatment decisions in patients after PEA. A comprehensive assessment including right heart catheterization 3 to 6 months after surgery seems advisable, but additional routine invasive hemodynamic assessments are probably not required. Asymptomatic patients with normalized hemodynamics 3 to 6 months after surgery can be followed noninvasively and do not need pulmonary vasodilator therapy. In these patients, recurrent pulmonary hypertension was rare, occurring in only 5 (1.3%) of 392 cases, 2 of whom had new thromboembolic events. Asymptomatic patients with mild residual pulmonary hypertension, as defined by a PAPm between 25 and 29 mm Hg, may also be followed carefully without further interventions, at least in the absence of right ventricular dysfunction.Symptomatic patients with any degree of residual pulmonary hypertension after surgery should receive medical therapy. New treatment options have emerged for CTEPH since the authors concluded their study. Riociguat, a stimulator of the soluble guanylate cyclase, has been approved for the treatment of patients with inoperable disease or residual pulmonary hypertension, as defined by PAPm≥25 mm Hg after PEA surgery.2 This treatment improves hemodynamics and exercise capacity, but it is unknown if it also improves survival.16,17 Balloon pulmonary angioplasty might be another therapeutic option for such patients, but there is limited experience with this procedure in patients presenting with residual or recurrent pulmonary hypertension after PEA surgery.18,19Taken together, the article by Cannon and coworkers clears the fog that has been blurring the view on residual pulmonary hypertension after PEA surgery. At the same time, this large, systematic follow-up study on patients undergoing PEA surgery reinforces the eminent role of surgical treatment for patients with CTEPH. Although only ≈50% of the operated patients normalized their pulmonary hemodynamics, the vast majority had substantial hemodynamic and functional improvement, and a 3-year survival of 90% is impressive in a disease that carries a high mortality risk in untreated patients.5,20 With such outcome data, PEA surgery will remain the preferred treatment of CTEPH, even in the absence of randomized, controlled trials.DisclosuresDr Hoeper has received fees for lectures and/or consultations from Actelion, Bayer, Gilead, GSK, and Pfizer.FootnotesThe opinions in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to Marius M. Hoeper, MD, Department of Respiratory Medicine, Hannover Medical School, 30623 Hannover, Germany. E-mail [email protected]References1. Kim NH, Delcroix M, Jenkins DP, Channick R, Dartevelle P, Jansa P, Lang I, Madani MM, Ogino H, Pengo V, Mayer E.Chronic thromboembolic pulmonary hypertension.J Am Coll Cardiol. 2013; 62(25 suppl):D92–D99. doi: 10.1016/j.jacc.2013.10.024.CrossrefMedlineGoogle Scholar2. Galiè N, Humbert M, Vachiery JL, Gibbs S, Lang I, Torbicki A, Simonneau G, Peacock A, Vonk Noordegraaf A, Beghetti M, Ghofrani A, Gomez Sanchez MA, Hansmann G, Klepetko W, Lancellotti P, Matucci M, McDonagh T, Pierard LA, Trindade PT, Zompatori M, Hoeper M.2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).Eur Respir J. 2015; 46:903–975. doi: 10.1183/13993003.01032-2015.CrossrefMedlineGoogle Scholar3. Lang I.Chronic thromboembolic pulmonary hypertension: a distinct disease entity.Eur Respir Rev. 2015; 24:246–252. doi: 10.1183/16000617.00001115.CrossrefMedlineGoogle Scholar4. Delcroix M, Lang I, Pepke-Zaba J, Jansa P, D'Armini AM, Snijder R, Bresser P, Torbicki A, Mellemkjaer S, Lewczuk J, Simkova I, Barberà JA, de Perrot M, Hoeper MM, Gaine S, Speich R, Gomez-Sanchez MA, Kovacs G, Jaïs X, Ambroz D, Treacy C, Morsolini M, Jenkins D, Lindner J, Dartevelle P, Mayer E, Simonneau G.Long-term outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry.Circulation. 2016; 133:859–871. doi: 10.1161/CIRCULATIONAHA.115.016522.LinkGoogle Scholar5. Lewczuk J, Piszko P, Jagas J, Porada A, Wójciak S, Sobkowicz B, Wrabec K.Prognostic factors in medically treated patients with chronic pulmonary embolism.Chest. 2001; 119:818–823.CrossrefMedlineGoogle Scholar6. Riedel M, Stanek V, Widimsky J, Prerovsky I.Longterm follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data.Chest. 1982; 81:151–158.CrossrefMedlineGoogle Scholar7. Moser KM, Braunwald NS.Successful surgical intervention in severe chronic thromboembolic pulmonary hypertension.Chest. 1973; 64:29–35.CrossrefMedlineGoogle Scholar8. Madani MM, Auger WR, Pretorius V, Sakakibara N, Kerr KM, Kim NH, Fedullo PF, Jamieson SW.Pulmonary endarterectomy: recent changes in a single institution's experience of more than 2,700 patients.Ann Thorac Surg. 2012; 94:97–103; discussion 103. doi: 10.1016/j.athoracsur.2012.04.004.CrossrefMedlineGoogle Scholar9. Jamieson SW, Auger WR, Fedullo PF, Channick RN, Kriett JM, Tarazi RY, Moser KM.Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period.J Thorac Cardiovasc Surg. 1993; 106:116–126; discussion 126.CrossrefMedlineGoogle Scholar10. Mayer E, Jenkins D, Lindner J, D'Armini A, Kloek J, Meyns B, Ilkjaer LB, Klepetko W, Delcroix M, Lang I, Pepke-Zaba J, Simonneau G, Dartevelle P.Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry.J Thorac Cardiovasc Surg. 2011; 141:702–710. doi: 10.1016/j.jtcvs.2010.11.024.CrossrefMedlineGoogle Scholar11. Skoro-Sajer N, Marta G, Gerges C, Hlavin G, Nierlich P, Taghavi S, Sadushi-Kolici R, Klepetko W, Lang IM.Surgical specimens, haemodynamics and long-term outcomes after pulmonary endarterectomy.Thorax. 2014; 69:116–122. doi: 10.1136/thoraxjnl-2013-203746.CrossrefMedlineGoogle Scholar12. Corsico AG, D'Armini AM, Cerveri I, Klersy C, Ansaldo E, Niniano R, Gatto E, Monterosso C, Morsolini M, Nicolardi S, Tramontin C, Pozzi E, Viganò M.Long-term outcome after pulmonary endarterectomy.Am J Respir Crit Care Med. 2008; 178:419–424. doi: 10.1164/rccm.200801-101OC.CrossrefMedlineGoogle Scholar13. Freed DH, Thomson BM, Berman M, Tsui SS, Dunning J, Sheares KK, Pepke-Zaba J, Jenkins DP.Survival after pulmonary thromboendarterectomy: effect of residual pulmonary hypertension.J Thorac Cardiovasc Surg. 2011; 141:383–387. doi: 10.1016/j.jtcvs.2009.12.056.CrossrefMedlineGoogle Scholar14. Hoeper MM, Bogaard HJ, Condliffe R, Frantz R, Khanna D, Kurzyna M, Langleben D, Manes A, Satoh T, Torres F, Wilkins MR, Badesch DB.Definitions and diagnosis of pulmonary hypertension.J Am Coll Cardiol. 2013; 62(25 suppl):D42–D50. doi: 10.1016/j.jacc.2013.10.032.CrossrefMedlineGoogle Scholar15. Cannon JE, Su L, Kiely DG, Page K, Toshner M, Swietlik E, Treacy C, Ponnaberanam A, Condliffe R, Sheares K, Taboada D, Dunning J, Tsui S, Ng C, Gopalan D, Screaton N, Elliot C, Gibbs S, Howard L, Corris P, Lordan J, Johnson M, Peacock A, MacKenzie-Ross R, Schreiber B, Coghlan G, Dimopoulos K, Wort SJ, Gaine S, Moledina S, Jenkins DP, Pepke-Zaba J.Dynamic risk stratification of patient long-term outcome after pulmonary endarterectomy: results from the United Kingdom national cohort.Circulation. 2016; 133:1761–1771.LinkGoogle Scholar16. Ghofrani HA, D'Armini AM, Grimminger F, Hoeper MM, Jansa P, Kim NH, Mayer E, Simonneau G, Wilkins MR, Fritsch A, Neuser D, Weimann G, Wang C; CHEST-1 Study Group. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension.N Engl J Med. 2013; 369:319–329. doi: 10.1056/NEJMoa1209657.CrossrefMedlineGoogle Scholar17. Simonneau G, D'Armini AM, Ghofrani HA, Grimminger F, Hoeper MM, Jansa P, Kim NH, Wang C, Wilkins MR, Fritsch A, Davie N, Colorado P, Mayer E.Riociguat for the treatment of chronic thromboembolic pulmonary hypertension: a long-term extension study (CHEST-2).Eur Respir J. 2015; 45:1293–1302. doi: 10.1183/09031936.00087114.CrossrefMedlineGoogle Scholar18. Kataoka M, Inami T, Hayashida K, Shimura N, Ishiguro H, Abe T, Tamura Y, Ando M, Fukuda K, Yoshino H, Satoh T.Percutaneous transluminal pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension.Circ Cardiovasc Interv. 2012; 5:756–762. doi: 10.1161/CIRCINTERVENTIONS.112.971390.LinkGoogle Scholar19. Fukui S, Ogo T, Morita Y, Tsuji A, Tateishi E, Ozaki K, Sanda Y, Fukuda T, Yasuda S, Ogawa H, Nakanishi N.Right ventricular reverse remodelling after balloon pulmonary angioplasty.Eur Respir J. 2014; 43:1394–1402. doi: 10.1183/09031936.00012914.CrossrefMedlineGoogle Scholar20. Condliffe R, Kiely DG, Gibbs JS, Corris PA, Peacock AJ, Jenkins DP, Hodgkins D, Goldsmith K, Hughes RJ, Sheares K, Tsui SS, Armstrong IJ, Torpy C, Crackett R, Carlin CM, Das C, Coghlan JG, Pepke-Zaba J.Improved outcomes in medically and surgically treated chronic thromboembolic pulmonary hypertension.Am J Respir Crit Care Med. 2008; 177:1122–1127. doi: 10.1164/rccm.200712-1841OC.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Jansa P, Ambrož D, Kuhn M, Dytrych V, Aschermann M, Černý V, Gressin V, Heller S, Kunstýř J, Širanec M, Song C, Linhart A, Lindner J and Muller A (2022) Epidemiology of chronic thromboembolic pulmonary hypertension (CTEPH) in the Czech Republic, Pulmonary Circulation, 10.1002/pul2.12038, 12:1, Online publication date: 1-Jan-2022. Calé R, Ferreira F, Pereira A, Repolho D, Sebaiti D, Alegria S, Vitorino S, Santos P, Pereira H, Brenot P and Loureiro M (2021) Safety and efficacy of balloon pulmonary angioplasty in a Portuguese pulmonary hypertension expert center, Revista Portuguesa de Cardiologia (English Edition), 10.1016/j.repce.2021.05.001, 40:10, (727-737), Online publication date: 1-Oct-2021. Calé R, Ferreira F, Pereira A, Repolho D, Sebaiti D, Alegria S, Vitorino S, Santos P, Pereira H, Brenot P and Loureiro M (2021) Segurança e eficácia da angioplastia pulmonar por balão em Portugal num centro de referência em hipertensão pulmonar, Revista Portuguesa de Cardiologia, 10.1016/j.repc.2020.10.016, 40:10, (727-738), Online publication date: 1-Oct-2021. Domínguez-Massa C, Pérez-Guillen M, Bueno-Codoñer M, Bel-Mínguez A, Valera-Martínez F and Hornero-Sos F (2019) Hipertensión pulmonar recidivada de causa tumoral: abordaje quirúrgico complejo, Cirugía Cardiovascular, 10.1016/j.circv.2019.05.001, 26:5, (232-235), Online publication date: 1-Sep-2019. Schoenfeld C, Hinrichs J, Olsson K, Kuettner M, Renne J, Kaireit T, Czerner C, Wacker F, Hoeper M, Meyer B and Vogel-Claussen J (2018) Cardio-pulmonary MRI for detection of treatment response after a single BPA treatment session in CTEPH patients, European Radiology, 10.1007/s00330-018-5696-4, 29:4, (1693-1702), Online publication date: 1-Apr-2019. Kratzert W, Boyd E, Saggar R and Channick R (2019) Critical Care of Patients After Pulmonary Thromboendarterectomy, Journal of Cardiothoracic and Vascular Anesthesia, 10.1053/j.jvca.2019.03.005, 33:11, (3110-3126), Online publication date: 1-Nov-2019. Domínguez-Massa C, Pérez-Guillen M, Bel-Mínguez A, Limón-Granja Á, Herrera-Melián P and Hornero-Sos F (2018) Reintervención precoz de la hipertensión tromboembólica crónica debida a sarcoma arterial pulmonar, Cirugía Cardiovascular, 10.1016/j.circv.2018.02.004, 25:5, (242-244), Online publication date: 1-Sep-2018. Olsson K, Wiedenroth C, Kamp J, Breithecker A, Fuge J, Krombach G, Haas M, Hamm C, Kramm T, Guth S, Ghofrani H, Hinrichs J, Cebotari S, Meyer K, Hoeper M, Mayer E, Liebetrau C and Meyer B (2017) Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience, European Respiratory Journal, 10.1183/13993003.02409-2016, 49:6, (1602409), Online publication date: 1-Jun-2017. Pepke-Zaba J, Ghofrani H and Hoeper M (2017) Medical management of chronic thromboembolic pulmonary hypertension, European Respiratory Review, 10.1183/16000617.0107-2016, 26:143, (160107), Online publication date: 31-Mar-2017. May 3, 2016Vol 133, Issue 18 Advertisement Article InformationMetrics © 2016 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.022595PMID: 27052412 Originally publishedApril 6, 2016 Keywordsendarterectomypulmonary embolismEditorialshypertension, pulmonaryPDF download Advertisement SubjectsVascular Disease
Referência(s)