Chronic Thromboembolic Pulmonary Hypertension Mahmud, Ehtisham; Madani, Michael M.; Kim, Nick H. ...
Journal of the American College of Cardiology,
05/2018, Letnik:
71, Številka:
21
Journal Article
Recenzirano
Odprti dostop
Chronic thromboembolic pulmonary hypertension (CTEPH), a rare consequence of an acute pulmonary embolism, is a disease that is underdiagnosed, and surgical pulmonary thromboendarterectomy (PTE) ...remains the preferred therapy. However, determination of operability is multifactorial and can be challenging. There is growing excitement for the percutaneous treatment of inoperable CTEPH with data from multiple centers around the world showing the clinical feasibility of balloon pulmonary angioplasty. Riociguat remains the only approved medical therapy for CTEPH patients deemed inoperable or with persistent pulmonary hypertension after PTE. We recommend that expert multidisciplinary CTEPH teams be developed at individual institutions. Additionally, optimal and standardized techniques for balloon pulmonary angioplasty need to be developed along with dedicated interventional equipment and appropriate training standards. In the meantime, the percutaneous revascularization option is appropriate for patients deemed inoperable in combination with targeted medical therapy, or those who have failed to benefit from surgery.
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Balloon pulmonary angioplasty (BPA) is an emerging treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who have inoperable, segmental/subsegmental disease, or ...residual disease after pulmonary endarterectomy. In the past decade, advances in the techniques for BPA have led to better clinical outcomes with improvements in hemodynamics, pulmonary perfusion, exercise tolerance, functional capacity, and quality of life. We present the experience with BPA at our university, the largest CTEPH center in the world, followed by reviewing the published data regarding the efficacy and safety of BPA in patients with CTEPH. There is increasing evidence to support that the initial hemodynamic improvement is sustained for ≥3 years after the procedure. Although infrequent, complications observed with BPA are associated with pulmonary vascular injury or rarely reperfusion pulmonary edema. As the technique for percutaneous pulmonary artery revascularization has improved, the procedural risk and complications have continued to decrease. This promising technique continues to develop, and future research is required to demonstrate the long-term benefits of BPA, standardize the technique, and define a uniform institutional infrastructure for providing BPA as a part of the treatment of CTEPH.
Cardiovascular Complications of Radiotherapy Lee, Michael S., MD; Finch, Will, MD; Mahmud, Ehtisham, MD
The American journal of cardiology,
11/2013, Letnik:
112, Številka:
10
Journal Article
Recenzirano
Chest radiotherapy is routinely used to treat malignancies such as Hodgkin disease and breast cancer but is commonly associated with a variety of cardiovascular complications involving the ...pericardium, myocardium, valves, coronary arteries, and conduction system. Cardiovascular complications are related to the total dose of radiation and the fractionation of the dose. They are usually progressive, portend poor prognosis, and are often refractory to treatment after significant radiation exposure. The mechanism of injury is multifactorial and likely involves endothelial damage of the microvasculature and coronary arteries and liberation of multiple inflammatory and profibrotic cytokines. In conclusion, routine follow-up with a cardiologist, which might include screening for valvular disease with echocardiography and coronary artery disease with computed tomography angiography or coronary artery calcium scoring, should be considered in patients with a history of chest radiotherapy.
...these procedures were performed with an acceptably low rate of complications (0.25% in-hospital death, 0.42% Q-wave myocardial infarction, 0.06% cerebrovascular accident, 0.15% cardiac tamponade, ...1.26% coronary artery perforation, and 0.10% emergency coronary artery bypass graft CABG surgery). ...successful CTO revascularization of at least 1 vessel was associated with decreased mortality (adjusted hazard ratio HR: 0.72; 95% CI: 0.62 to 0.83; p < 0.001) at a median follow-up of 2.65 years (interquartile range: 1.59 to 3.83 years).
Objectives
To assess the long‐term safety and efficacy of robotic percutaneous coronary revascularization for use in complex coronary lesions.
Background
Robotically assisted percutaneous coronary ...intervention (PCI) is safe and feasible in simple coronary lesions and has excellent short‐term procedural and clinical outcomes for complex lesions; however, long‐term safety and efficacy outcomes are unknown.
Methods
A total of 103 consecutive patients underwent a total of 108 robotic (R)‐PCI procedures (age 68.1; 78.3% male) over 18 months, and 210 patients underwent a total of 226 manual (M)‐PCI procedures (age 67.5; 78.1% male) during the same period. Patients were subsequently followed and both 6‐month and 12‐month major adverse cardiovascular events (MACE), comprised of any death, stroke, myocardial infarction, or target vessel revascularization, are reported and compared.
Results
There was no difference between the two groups with regard to overall MACE at 6 months (R‐PCI 5.8% vs. M‐PCI 3.3%, P = 0.51) or at 12 months (R‐PCI 7.8% vs. M‐PCI 8.1%, P = 0.92). There was no difference between the individual components of the primary combined endpoint at either time point. No access site complications occurred in either cohort that met BARC III or higher criteria.
Conclusions
At the 6‐ and 12‐month time points following R‐PCI, no difference in clinical outcomes or safety measures was observed as compared to M‐PCI.
Reducing door-to-balloon (D + B) time during primary percutaneous coronary intervention for patients with ST-segment elevation myocardial infarction (STEMI) reduces mortality. Prehospital 12-lead ...electrocadiography (ECG) with cardiac catheterization laboratory (CCL) activation may reduce D + B time. Paramedic-performed ECG was initiated in the city of San Diego in January 2005 with STEMI diagnosis based on an automated computer algorithm. We undertook this study to determine the effect of prehospital CCL activation on D + B time for patients with acute STEMI brought to our institution. All data were prospectively collected for patients with STEMI including times to treatment and clinical outcomes. We evaluated 78 consecutive patients with STEMI from January 2005 to June 2006, and the study group consisted of all patients with prehospital activation of the CCL (field STEMI; n = 20). The control groups included concurrently-treated patients with STEMI during the same period who presented to the emergency department (nonfield STEMI; n = 28), and all patients with STEMI treated in the preceding year (2004) (historical STEMI; n = 30). Prehospital CCL activation significantly reduced D + B time (73 ± 19 minutes field STEMI, 130 ± 66 minutes nonfield STEMI, 141 ± 49 minutes historical STEMI; p <0.001) with significant reductions in door-to-CCL and CCL-to-balloon times as well. The majority of patients with field STEMI achieved D + B times of <90 minutes (80% field STEMI, 25% nonfield STEMI, 10% historical STEMI; p <0.001). In conclusion, this study demonstrates that prehospital electrocardiographic diagnosis of STEMI with activation of the CCL markedly reduces D + B time.
Chronic thromboembolic pulmonary hypertension is a form of precapillary pulmonary hypertension resulting from the incomplete resolution of pulmonary thromboemboli and formation of chronic, fibrotic, ...flow-limiting obstructions within the pulmonary vasculature. The progression of chronic thromboembolic disease is associated with the development of pulmonary hypertension, right heart failure, and diminished patient function. Surgical pulmonary thromboendarterectomy to extract thromboembolic disease is curative and the primary treatment option for chronic thromboembolic pulmonary hypertension. For patients who are not surgical candidates, balloon pulmonary angioplasty (BPA) is a percutaneous treatment option that uses angioplasty techniques to dilate diseased pulmonary arteries, disrupt organized flow-limiting obstructions, revascularize underperfused lung regions, improve pulmonary vascular hemodynamics, and restore patient function. BPA has undergone refinement and worldwide adoption since its inception, leading to advancements in the equipment used, technical approach, and complication management for each procedure. The approach to modern BPA, its attendant complications, and contemporary treatment outcomes are discussed in this state-of-the-art review.
The relationships between oxidation-specific epitopes (OSE) and lipoprotein (a) Lp(a) and progressive atherosclerosis and plaque rupture have not been determined. Coronary artery sections from sudden ...death victims and carotid endarterectomy specimens were immunostained for apoB-100, oxidized phospholipids (OxPL), apo(a), malondialdehyde-lysine (MDA), and MDA-related epitopes detected by antibody IK17 and macrophage markers. The presence of OxPL captured in carotid and saphenous vein graft distal protection devices was determined with LC-MS/MS. In coronary arteries, OSE and apo(a) were absent in normal coronary arteries and minimally present in early lesions. As lesions progressed, apoB and MDA epitopes did not increase, whereas macrophage, apo(a), OxPL, and IK17 epitopes increased proportionally, but they differed according to plaque type and plaque components. Apo(a) epitopes were present throughout early and late lesions, especially in macrophages and the necrotic core. IK17 and OxPL epitopes were strongest in late lesions in macrophage-rich areas, lipid pools, and the necrotic core, and they were most specifically associated with unstable and ruptured plaques. Specific OxPL were present in distal protection devices. Human atherosclerotic lesions manifest a differential expression of OSEs and apo(a) as they progress, rupture, and become clinically symptomatic. These findings provide a rationale for targeting OSE for biotheranostic applications in humans.
Objectives This study sought to assess whether oxidized lipids are released downstream from obstructive plaques after percutaneous coronary and peripheral interventions using distal protection ...devices. Background Oxidation of lipoproteins generates multiple bioactive oxidized lipids that affect atherothrombosis and endothelial function. Direct evidence of their role during therapeutic procedures, which may result in no-reflow phenomenon, myocardial infarction, and stroke, is lacking. Methods The presence of specific oxidized lipids was assessed in embolized material captured by distal protection filter devices during uncomplicated saphenous vein graft, carotid, renal, and superficial femoral artery interventions. The presence of oxidized phospholipids (OxPL) and oxidized cholesteryl esters (OxCE) was evaluated in 24 filters using liquid chromatography, tandem mass spectrometry, enzyme-linked immunosorbent assays, and immunostaining. Results Phosphatidylcholine-containing OxPL, including (1-palmitoyl-2-9-oxo-nonanoyl PC), representing a major phosphatidylcholine-OxPL molecule quantitated within plaque material, 1-palmitoyl-2-(5-oxo-valeroyl)-sn-glycero-3-phosphocholine, and 1-palmitoyl-2-glutaroyl-sn-glycero-3-phosphocholine, were identified in the extracted lipid portion from all vascular beds. Several species of OxCE, such as keto, hydroperoxide, hydroxy, and epoxy cholesteryl ester derivatives from cholesteryl linoleate and cholesteryl arachidonate, were also present. The presence of OxPL was confirmed using enzyme-linked immunoassays and immunohistochemistry of captured material. Conclusions This study documents the direct release and capture of OxPL and OxCE during percutaneous interventions from multiple arterial beds in humans. Entrance of bioactive oxidized lipids into the microcirculation may mediate adverse clinical outcomes during therapeutic procedures.
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