Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter

McCabe, Colm; White, Paul A.; Hoole, Stephen P.; Axell, Richard G.; Priest, Andrew N.; Gopalan, Deepa; Taboada, Dolores; Ross, Robert V. MacKenzie; Morrell, Nicholas W.; Shapiro, Leonard M.; Pepke‐Zaba, Joanna

doi:10.1152/japplphysiol.01123.2013

Cited by 95 publications

(82 citation statements)

References 35 publications

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“…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: Discussionmentioning

confidence: 49%

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: Discussionmentioning

confidence: 49%

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

et al. 2014

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“…Most recently, high-fidelity RV pressure and volume measurements, and single-beat Emax calculations have been reported in a small series of patients with chronic thromboembolic pulmonary hypertension (CTEPH), a condition with similar symptomatology to that of PAH [21]. This limited size report confirms the importance of systolic function adaptation with an increased Emax to maintain RV-arterial coupling in the face of severe increases in PAP, in agreement with previous studies in various animal species [10].…”

Section: Systolic Function Of the Right Ventriclementioning

confidence: 99%

The right ventricle in pulmonary arterial hypertension

2014

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Pulmonary arterial hypertension (PAH) is a right heart failure syndrome. In early-stage PAH, the right ventricle tends to remain adapted to afterload with increased contractility and little or no increase in right heart chamber dimensions. However, less than optimal right ventricular (RV)-arterial coupling may already cause a decreased aerobic exercise capacity by limiting maximum cardiac output. In more advanced stages, RV systolic function cannot remain matched to afterload and dilatation of the right heart chamber progressively develops. In addition, diastolic dysfunction occurs due to myocardial fibrosis and sarcomeric stiffening. All these changes lead to limitation of RV flow output, increased right-sided filling pressures and under-filling of the left ventricle, with eventual decrease in systemic blood pressure and altered systolic ventricular interaction. These pathophysiological changes account for exertional dyspnoea and systemic venous congestion typical of PAH. Complete evaluation of RV failure requires echocardiographic or magnetic resonance imaging, and right heart catheterisation measurements. Treatment of RV failure in PAH relies on: decreasing afterload with drugs targeting pulmonary circulation; fluid management to optimise ventricular diastolic interactions; and inotropic interventions to reverse cardiogenic shock. To date, there has been no report of the efficacy of drug treatments that specifically target the right ventricle. @ERSpublicationsThe compensatory adaptation of right ventricular structure and function is linked to symptoms and prognosis in PAH http://ow.ly/D5W9R

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“…In addition, following an episode of acute pulmonary emboli a growing number of patients are being identified with persistent dyspnoea in the absence of pulmonary hypertension (mean pulmonary arterial pressure ,25 mmHg at rest), affecting their exercise capacity and quality of life [16]. The symptoms of breathlessness in these patients can be related to excessive dead space ventilation, pulmonary hypertension on exercise and/or maladaptation of the right ventricle to the decreased pulmonary artery compliance [17,18]. The prognosis and risk of progression to a more severe form of pulmonary hypertension, however, remains unclear.…”

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confidence: 99%

Chronic thromboembolic pulmonary hypertension: do we need a new definition?

Perrot

Mayer²

2014

Eur Respir J

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@ERSpublications Selection of patients for pulmonary endarterectomy in the absence of PH requires thorough evaluation http://ow.ly/CEO3MChronic thromboembolic pulmonary hypertension (CTEPH) is the end result of persistent obstruction of the pulmonary arteries following episodes of acute and/or recurrent pulmonary emboli [1]. Pulmonary hypertension probably stems from a smaller pulmonary arterial cross sectional area due to thrombus organisation and a redistribution of blood flow through the patent pulmonary arterial bed producing an additional microvasculopathy [2]. Consequently many patients develop pulmonary hypertension despite adequate anticoagulation [3]. Once pulmonary hypertension occurs, the prognosis is poor due to right heart failure with a survival similar to other forms of pre-capillary pulmonary hypertension [4]. Patients suffering from CTEPH typically present with progressive dyspnoea that worsens over a period of months to years [5]. Dyspnoea is related to hypoxaemia, dead space ventilation and right heart dysfunction, severely affecting the quality of life [6,7].Pulmonary endarterectomy is the treatment of choice for CTEPH. The surgery leads to major clinical improvement due to improved haemodynamic parameters and oxygenation, and a reduction in dead space ventilation [7,8]. The surgery is curative in a large proportion of patients with resolution of the pulmonary hypertension. Over the past 20 years, the technique of pulmonary endarterectomy under deep hypothermic circulatory arrest has been refined and can currently be performed with reproducible results across an increasing number of specialised centres. Expert centre series and a recent prospective multicentre registry demonstrated that pulmonary endarterectomy can be carried out safely in experienced centres with an overall operative mortality of ,5% [8,9]. The risk of surgery depends of the severity of the disease and the mortality can be inferior to 1% in patients with limited vasculopathy and adequate right ventricular function [10,11]. Long-term results are favourable with regard to survival, exercise capacity and quality of life [12,13].In the era of successful surgical therapy, CTEPH, which was considered to be a rare entity, is being diagnosed more and more frequently. Several recent prospective studies have shown that the prevalence of CTEPH can be as high as 5% after acute pulmonary embolism [14,15]. In addition, following an episode of acute pulmonary emboli a growing number of patients are being identified with persistent dyspnoea in the absence of pulmonary hypertension (mean pulmonary arterial pressure ,25 mmHg at rest), affecting their exercise capacity and quality of life [16]. The symptoms of breathlessness in these patients can be related to excessive dead space ventilation, pulmonary hypertension on exercise and/or maladaptation of the right

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Right ventricular dysfunction in chronic thromboembolic obstruction of the pulmonary artery: a pressure-volume study using the conductance catheter

Cited by 95 publications

References 35 publications

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

Outcome of pulmonary endarterectomy in symptomatic chronic thromboembolic disease

The right ventricle in pulmonary arterial hypertension

Chronic thromboembolic pulmonary hypertension: do we need a new definition?

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