Angioplastia con balón a arterias pulmonares en una paciente con hipertensión pulmonar tromboembólica crónica / Angioplastia com balão de artérias pulmonares em uma paciente com hipertensão pulmonar tromboembólica crônica / A case of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

La hipertensión pulmonar tromboembólica crónica presenta un tratamiento curativo, siendo la endarterectomía pulmonar (EP) la opción terapéutica establecida. Sin embargo, la angioplastia con balón a arterias pulmonares puede ser considerada una alternativa viable en pacientes inoperables o en aquellos que persisten con hipertensión pulmonar tras una EP. Se reporta a continuación el primer caso de angioplastia con balón a arterias pulmonares realizada en un centro de Argentina.

Chronic thromboembolic pulmonary hypertension presents a curative treatment, with pulmonary endarterectomy being the established therapeutic option. However, balloon angioplasty to pulmonary arteries may be considered an alternative therapeutic option for patients with inoperable or residual disease after surgery. Herewith, we report the first case of chronic thromboembolic pulmonary hypertension treated with balloon pulmonary angioplasty in Argentina.

A hipertensão pulmonar tromboembólica crônica tem um tratamento curativo, a endarterectomia pulmonar (EP), a opção terapêutica estabelecida. No entanto, angioplastia com balão de artérias pulmonares pode ser considerado uma alternativa viável em pacientes inoperáveis ou aqueles que persistem com a hipertensão pulmonar após EP. Relatamos o primeiro caso de angioplastia pulmonar com balão no centro da Argentina.

Chronic Thromboembolic Pulmonary Hypertension: Experience from a Single Center in Mexico.

INTRODUCTION: Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by precapillary pulmonary hypertension secondary to vaso-occlusive pulmonary vasculopathy and is classified as Pulmonary Hypertension Group 4. The aim of this study is to report the clinical experience of CTEPH in Mexico. METHODS: Consecutive patients diagnosed with CTEPH were identified from the Registro de Pacientes con Hipertension Pulmonar del Instituto de Seguridad y Servicio Social de los Trabajadores del Estado (REPHPISSSTE) registry between January 2009 and February 2014. Right heart catheterization was not routinely performed prior to August 2010 in the work-up of CTEPH. RESULTS: We identified 50 patients with CTEPH; their median age was 63 years and 58 % were female. Patients had multiple associated co-morbidities and moderate hemodynamic impairment. All patients were treated with anticoagulation. Despite surgical evaluation for pulmonary endarterectomy (PEA), only one patient underwent PEA given the lack of infrastructure for post-operative care and lack of insurance for this procedure. Most of the patients were treated with sildenafil, bosentan, or both, with increasing use of rivaroxaban and sildenafil in recent years. The overall survival of the cohort was similar to that reported in other international registries, despite the limitations of care imposed by drug availability and surgical feasibility. CONCLUSION: This is the first report on the CTEPH experience in Mexico. It highlights the similarity of patients in the REPHPISSSTE registry to those in international registries as well as the challenges that clinicians face in a resource-limited setting.

Medical and surgical management for chronic thromboembolic pulmonary hypertension: a single center experience.

INTRODUCTION: Pulmonary endarterectomy (PE) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). The aim of this study was to analyze our experience in the medical and surgical management of CTEPH. METHODS: We included 80 patients diagnosed with CTEPH between January 2000 and July 2012. Thirty two patients underwent PE and 48 received medical treatment (MT). We analyzed functional class (FC), six-minute walking distance (6MWD) and pulmonary hemodynamics. Mortality in both groups and periods were analyzed. RESULTS: Patients who underwent PE were younger, mostly men, and had longer 6MWD. No differences were observed in pulmonary hemodynamics or FC at diagnosis. One year after treatment, all PE patients versus 41% in MT group were at FCI-II. At follow-up, the PE group showed greater increase in 6MWD, and greater reduction in mean pulmonary arterial pressure and pulmonary vascular resistance than the MT group (P<.05). Overall survival in the MT group at 1 and 5years was 83% and 69%, respectively. Conditional survival in patients alive 100days post-PE at 1 and 5years was 95% and 88%, respectively. Surgical mortality in operated patients in the first period (2000-2006) was 31,3%, and 6,3% in the second (2007-2012). CONCLUSIONS: PE provides good clinical results, and improves pulmonary hemodynamics in patients who successfully overcome the immediate postoperative period. After a learning period, the current operatory mortality in our center is similar to international standards.

Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: How can patients be better selected?

Chronic thromboembolic pulmonary hypertension (CTEPH) comprises organizing thrombotic obstructions in the pulmonary arteries by nonresolving thromboemboli, formation of fibrosis and remodeling of pulmonary blood vessels. Surgical pulmonary endarterectomy (PEA) is the therapy of choice for patients with surgically accessible CTEPH, which leads to a profound improvement in hemodynamics, functional class and survival. Selecting the candidates that will benefit from surgery is still a challenging task. Criteria for surgical suitability have been described but the decision-making for or against surgical intervention remains still subjective. The optimal characterization of the reciprocal contribution of large vessel and small vessel disease in the elevation of pulmonary vascular resistance is crucial for the indication and outcome of PEA. Recently, Toshner et al intended to validate the partition resistance into small and large vessels compartments (upstream resistance: Rup) by the occlusion technique in the preoperative assessment of PEA. We discuss the advantages and disadvantages of Rup and compare it with other hemodynamic predictor to evaluate operative risk in CTEPH patients.