Endobronchial Valves in Treatment of Persistent Air Leak: European case-series study and Best Practice Recommendations - from an Expert Panel.

Introduction Persistent air leak (PAL) is associated with prolonged hospitalization, high morbidity and increased treatment costs. Conservative treatment consists of observation, chest tube drainage and pleurodesis. Guidelines recommend surgical evaluation if air leak does not respond after 3-5 days. One-way endobronchial valves (EBV) have been proposed as a treatment option for patients with PAL in which surgical treatment is not feasible, high risk or has failed. We aimed to provide a comprehensive overview of reported EBV use for PAL and issue best practice recommendations based on multicenter experience. Methods We conducted a retrospective observational case-series study at four different European academic hospitals and provided best practice recommendations based on our experience. A systematic literature review was performed to summarize the current knowledge on EBV in PAL. Results We enrolled 66 patients, male (66.7%), median age 59.5 years. The most common underlying lung disease was chronic obstructive pulmonary disease (39.4%), and lung cancer (33.3%). The median time between pneumothorax and valve placement was 24.5 days (IQR: 14.0-54.3). Air leak resolved in 40/66 patients (60.6%) within thirty days after endobronchial valve treatment. Concerning safety outcome, no procedure related mortality was reported and complication rate was low (6.1%). 5 patients (7.6%) died in the first 30 days after intervention. Conclusion EBV placement is a treatment option in patients with persistent air leak (PAL). In this multicenter case-series of high risk patients not eligible for lung surgery, we show that EBV placement resulted in air leak resolution in 6 out of 10 patients with a low complication rate. Considering the minimally invasive nature of EBV to treat PAL as opposed to surgery, further research should investigate if EBV treatment should be expanded in low to intermediate risk PAL patients.

Pulmonary hypertension-targeted therapies in heart failure: A systematic review and meta-analysis.

BACKGROUND: Pulmonary hypertension (PH) due to left heart failure (HF) is the most common form of PH. However, treatment is unclear because there are conflicting results about safety and efficacy of PH-targeted therapies. OBJECTIVES: To assess the effects of PH-targeted therapy on exercise capacity in HF patients. METHODS: MEDLINE, EMBASE and the Cochrane Library were searched from January 1990 to July 2017 for randomized controlled trials comparing PH-targeted therapies to conventional therapy in HF. The primary outcome was to assess the effects on exercise capacity. Secondary outcomes included mortality, hospitalisation, NT-proBNP levels, echocardiographic and hemodynamics parameters and discontinuation rate. RESULTS: 22 studies were included (n = 5448), including 3, 8 and 11 studies with low, high and unknown risk of bias, respectively. PH-targeted therapies were associated with an improvement of exercise capacity (standardized mean difference 0.29;95%CI:0.08-0.50, p = 0.006). Pre-specified subgroup analyses found that this improvement was predominantly observed in studies evaluating phosphodiesterase-5 inhibitors and prostanoids and in patients with reduced ejection fraction. Moreover, systolic pulmonary artery pressure measured by echocardiography was improved (mean difference: -7.5mmHg; [95%CI]: -14.9,-0.1, p = 0.05), which was also entirely driven by studies evaluating phosphodiesterase-5 inhibitors. However, PH-targeted therapies were associated with an increased treatment discontinuation rates and a potential increase in mortality compared to standard treatment. CONCLUSIONS: In conclusion, PH-targeted therapies and especially phosphodiesterase-5 inhibitors may improve exercise capacity in patients with HF. However, an increase in adverse outcomes was likely. Moreover, most studies were at high or unknown risk of bias, precluding confident conclusions about the effects of PH-targeted therapies.

Pulmonary micro-tumor emboli resulting in paradoxical emboli: a case report.

Pulmonary tumor embolism (PTE) is a rare manifestation of cancer. It is characterized by the presence of tumor cell emboli in the pulmonary arterioles and capillaries leading to an elevation of pulmonary vascular resistance. The ante-mortem diagnosis is difficult. We report a case of PTE associated with recurrent breast cancer that presented with neurological symptoms due to paradoxical cerebral embolism.