Inefficient exercise gas exchange identifies pulmonary hypertension in chronic thromboembolic obstruction following pulmonary embolism

McCabe, Colm; Deboeck, Gaël; Harvey, Ian; Ross, Robert; Gopalan, Deepa; Screaton, Nicholas; Pepke‐Zaba, Joanna

doi:10.1016/j.thromres.2013.09.032

Cited by 71 publications

(53 citation statements)

References 35 publications

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“…A small and selected group of patients from our cohort participated in a study looking at CPET in patients with thromboembolic disease. This study demonstrated that CTED patients have impaired right ventricular adaptation to exercise and inefficient gas exchange on exertion [26]. Moreover, our study on right ventricular mechanics using conductance catheter derived pressure-volume loops showed delayed right ventricular relaxation in these patients [27].…”

Section: Discussionsupporting

confidence: 52%

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

et al. 2014

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Chronic thromboembolic disease is characterised by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment with pulmonary endarterectomy may improve symptoms and prevent disease progression. We sought to assess the outcome of pulmonary endarterectomy in symptomatic patients with chronic thromboembolic disease.Patients with symptomatic chronic thromboembolic disease and a mean pulmonary artery pressure ,25 mmHg at baseline with right heart catheterisation and treated with pulmonary endarterectomy between January 2000 and July 2013 were identified. Patients were reassessed at 6 months and at 1 year following surgery.A total of 42 patients underwent surgery and the median length of stay in hospital was 11 days. There was no in-hospital mortality but complications occurred in 40% of patients. At 1 year, following surgery, 95% of the patients remained alive. There was a significant symptomatic improvement with 95% of patients in the New York Heart Association functional classes I or II at 6 months. There was a significant improvement in quality of life assessed by the Cambridge pulmonary hypertension outcome review questionnaire.In this carefully selected cohort of chronic thromboembolic disease patients, pulmonary endarterectomy resulted in significant improvement in symptoms and quality of life. Appropriate patient selection is paramount given the known surgical morbidity and mortality, and surgery should only be performed in expert centres. @ERSpublications Pulmonary endarterectomy improves symptoms and quality of life in patients with chronic thromboembolic disease http://ow.ly/AeECt

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Section: Discussionsupporting

confidence: 52%

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

et al. 2014

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“…However, during exercise, CTED subjects showed a relevant increase in P(A-a) O 2 . McCabe et al [13] also showed a higher P(A-a) O 2 in CTEPH than in CTED patients; however, these authors did not provide blood gas analysis and therefore no P(A-a) O 2 and P(a-ET) CO 2 data for the control group [13]. Furthermore, McCabe et al [13] did not perform right heart catheterization under exercise in the CTED group and no right heart catheterization in their control group.…”

Section: Discussionmentioning

confidence: 99%

“…Chronic thromboembolic vascular disease (CTED) has been described clinically as pulmonary vascular obstruction with an mPAP at rest of <25 mm Hg [7,11,12,13,14]. Recently, successful PEA in patients with CTED has been described [14].…”

Section: Introductionmentioning

confidence: 99%

Functional Characterization of Patients with Chronic Thromboembolic Disease

Held

Kolb²,

Grün³

et al. 2016

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Background: Patients with chronic thromboembolic pulmonary disease (CTED) have persistent pulmonary vascular obstruction and exercise intolerance without pulmonary hypertension at rest and may benefit from pulmonary endarterectomy. However, up to now, CTED has been poorly characterized. Objectives: This study aimed to analyze the exercise capacity and limiting factors in CTED. Methods: We compared right heart catheterization and cardiopulmonary exercise test results of patients with CTED [mean pulmonary artery pressure (mPAP) at rest <25 mm Hg, n = 10], chronic thromboembolic pulmonary hypertension (CTEPH, n = 31) and a control group (n = 41) presenting with dyspnea but normal pulmonary vascular imaging and excluded pulmonary hypertension. Results: Subjects with CTED show a reduced oxygen uptake [median 76/interquartile range (IQR) 22% pred.] and work rate (median 76/IQR 21 W). The work rate was significantly lower compared to control subjects (p = 0.04) but not significantly different from CTEPH patients (p = 0.66). Oxygen pulse and breathing reserve were normal. CTED subjects showed decreased end-tidal CO₂ at anaerobic threshold (28.4/4.3 mm Hg), an elevated VE/VCO₂ slope (42.5/23.5), breathing equivalents (EQO₂ 32.0/8.7, EQCO₂ 39.5/8.8), alveolar-capillary oxygen gradient (34.7/15.5 mm Hg) and capillary end-tidal carbon dioxide gradient (8.8/5.7 mm Hg) compared to control subjects (p < 0.001). The degree of limitation was similar to that in CTEPH. Conclusions: Despite an mPAP of <25 mm Hg, subjects with CTED show objective functional impairment and similar limitations to patients with CTEPH. Functional limitation is characterized by gas exchange disturbance and ineffective ventilation.

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“…Thus, the non‐PH group included patients who had a history of pulmonary embolism and were not fully characterized. Moreover, patients with chronic thromboembolic disease with persistent pulmonary thromboembolic occlusions with near‐normal pulmonary haemodynamics at rest experience breathlessness and low P ET CO 2 during exercise . However, showing the differences between PH and non‐PH with suspected PH is of even greater value.…”

Section: Discussionmentioning

confidence: 99%

“…Moreover, patients with chronic thromboembolic disease with persistent pulmonary thromboembolic occlusions with near-normal pulmonary haemodynamics at rest experience breathlessness and low P ET CO 2 during exercise. 37,38 However, showing the differences between PH and non-PH with suspected PH is of even greater value. With this, the findings need to be confirmed in future multicentre studies with a large sample.…”

Section: Study Limitationsmentioning

confidence: 99%

Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension

et al. 2019

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Background and objective Clinical presentations associated with chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH) at rest are highly similar. Differentiating between CTEPH and PAH using non‐invasive techniques remains challenging. Thus, we examined whether analysis of ventilatory gas in response to postural changes can be useful as a non‐invasive screening method for pulmonary hypertension (PH), and help differentiate CTEPH from PAH. Methods We prospectively enrolled 90 patients with suspected PH and performed right heart catheterization, ventilation/perfusion scan and ventilatory gas analysis. Various pulmonary function parameters were examined in the supine and sitting postures, and postural changes were calculated (Δ(supine − sitting)). Results In total, 25 patients with newly diagnosed PAH, 40 patients with newly diagnosed CTEPH and 25 non‐PH patients were included. ΔEnd‐tidal CO2 pressure (PETCO2) was significantly lower in patients with CTEPH and PAH than in non‐PH patients (both P < 0.001). ΔPETCO2 < 0 mm Hg could effectively differentiate PH from non‐PH (area under the curve (AUC) = 0.969, sensitivity = 89%, specificity = 100%). Postural change from sitting to supine significantly increased the ratio of ventilation to CO2 production (VE/VCO2) in the CTEPH group (P < 0.001). By contrast, VE/VCO2 significantly decreased in the PAH group (P = 0.001). Notably, CTEPH presented with higher ΔVE/VCO2 than PAH, although no differences were observed in haemodynamic and echocardiographic parameters between the two groups (P < 0.001). Furthermore, ΔVE/VCO2 > 0.8 could effectively differentiate CTEPH from PAH (AUC = 0.849, sensitivity = 78%, specificity = 88%). Conclusion Postural changes in ventilatory gas analysis are useful as a non‐invasive bedside evaluation to screen for the presence of PH and distinguish between CTEPH and PAH.

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Inefficient exercise gas exchange identifies pulmonary hypertension in chronic thromboembolic obstruction following pulmonary embolism

Cited by 71 publications

References 35 publications

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

Functional Characterization of Patients with Chronic Thromboembolic Disease

Non‐invasive screening using ventilatory gas analysis to distinguish between chronic thromboembolic pulmonary hypertension and pulmonary arterial hypertension

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