ABSTRACT
ABSTRACT Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious and debilitating disease caused by occlusion of the pulmonary arterial bed by hematic emboli and by the resulting fibrous material. Such occlusion increases vascular resistance and, consequently, the pressure in the region of the pulmonary artery, which is the definition of pulmonary hypertension. The increased load imposed on the right ventricle leads to its progressive dysfunction and, finally, to death. However, CTEPH has a highly significant feature that distinguishes it from other forms of pulmonary hypertension: the fact that it can be cured through treatment with pulmonary thromboendarterectomy. Therefore, the primary objective of the management of CTEPH should be the assessment of patient fitness for surgery at a referral center, given that not all patients are good candidates. For the patients who are not good candidates for pulmonary thromboendarterectomy, the viable therapeutic alternatives include pulmonary artery angioplasty and pharmacological treatment. In these recommendations, the pathophysiological bases for the onset of CTEPH, such as acute pulmonary embolism and the clinical condition of the patient, will be discussed, as will the diagnostic algorithm to be followed and the therapeutic alternatives currently available.
RESUMO A hipertensão pulmonar tromboembólica crônica (HPTEC) é uma doença grave e debilitante, causada pela oclusão do leito arterial pulmonar por êmbolos hemáticos e por material fibroso induzido pela presença desses êmbolos. Essa oclusão eleva a resistência vascular e, por consequência, a pressão do território arterial pulmonar, caracterizando a presença de hipertensão pulmonar. Esse aumento da carga imposta ao ventrículo direito leva a progressiva insuficiência do mesmo e, finalmente, ao óbito. No entanto, ao contrário das outras formas de hipertensão pulmonar, a HPTEC possui uma particularidade muito significativa: a existência de tratamento potencialmente curativo através da tromboendarterectomia pulmonar. Dessa forma, o objetivo primordial do manejo deve ser a avaliação do potencial cirúrgico do paciente em um centro de referência em HPTEC. Entretanto, nem todos os pacientes podem ser submetidos à cirurgia. Para esses pacientes outras alternativas terapêuticas viáveis são a angioplastia de artérias pulmonares e o tratamento farmacológico. Nestas recomendações, discutir-se-ão as bases fisiopatológicas para o surgimento de HPTEC, a partir da embolia pulmonar aguda, bem como o quadro clínico apresentado pelo paciente, o algoritmo diagnóstico a ser seguido e as alternativas terapêuticas disponíveis.
ABSTRACT
This paper is about the Guideline for Ventilation / Perfusion Scintigraphy. It has been developed by the Brazilian Society of Nuclear Medicine to be a best practices guide used in Nuclear Medicine. Its function is to be an educational tool to help the Nuclear Medicine Services in Brazil to guarantee a quality care to the patients
Subject(s)
Humans , Male , Female , Ventilation-Perfusion Ratio , Guidelines as Topic/standards , Pulmonary Artery/pathology , Pulmonary Embolism/complications , Pulmonary Embolism/diagnostic imaging , Diagnostic Imaging/methods , Radionuclide Imaging/methods , Nuclear Medicine/standardsABSTRACT
INTRODUÇÃO: O paciente com insuficiência cardíaca desenvolve aumento da pressão pulmonar por mecanismo retrógrado e a hipertensão arterial pulmonar (HP) é um marcador de mau prognóstico. OBJETIVO: Correlacionar pressão pulmonar ao ecogardiograma (eco) e ao cateterismo, em pacientes em lista de espera para transplante cardíaco (TC), especialmente nos chagásicos. MÉTODOS: Avaliamos 90 pacientes no HC-UFMG entre 2004 e 2009. Todos realizaram cateterismo e eco no pré-transplante. A idade média foi de 45,5 anos, sendo 68(75,6%) homens, 42(46,7%) chagásicos, 32(35,6%) portadores de miocardiopatia dilatada e 10(11,1%) isquêmicos. RESULTADOS: A eco-PSAP (pressão sistólica arterial pulmonar) média foi de 45 ± 12mmHg. A cat-PSAP média foi de 47 ± 14mmHg. A eco-PSAP-chagásicos foi 41,7 ±12,5 mmHg e não-chagásicos, 47,6 ±12,8 mmHg P=0,04. A cat-PSAP-chagásicos foi de 46 ±12,1 mmHg e não-chagásicos 48,7±12,8mmHg; P=0,43. Oito pacientes apresentavam cat-PSAP>60. A correlação entre a eco-PSAP e o cat-PSAP nos chagásicos foi r=0,45, P=0,008 e nos não-chagásicos de r=0,66, P<0,001. A eco-PSAP-chagásico >32,5mmHg tem uma sensibilidade de 79% e especificidade de 75% para diagnosticar HP, com área sob a curva ROC de 0,819. A eco-PSAP-não chagásico>35,5 mmHg tem sensibilidade de 82% e especificidade de 70% para HP, com área sob a curva ROC de 0,776. CONCLUSÕES: Há boa correlação entre a eco-PSAP e a cat-PSAP (r=0,54) entre os pacientes em fila de espera. A eco-PSAP foi menor no grupo dos chagásicos. O ecocardiograma é um método útil para diagnosticar e monitorar a pressão pulmonar previamente ao TC, especialmente em pacientes chagásicos. Entretanto, não é possível prescindirmos do cateterismo para avaliar a reatividade pulmonar com o teste com vasodilatador e indicar com segurança o TC mesmo nos pacientes chagásicos.
INTRODUCTION: The patients suffering heart failure develop an increase in pulmonary pressure because of a retrograde mechanism. The pulmonary hypertension is a prognostic marker. OBJECTIVE: The aim of this study is to correlate pulmonary hypertension measured by echocardiogram versus catheterization in pre-heart transplant patients on waiting list. METHODS: Data from 90 patients of the Clinical Hospital UFMG were collected between 2004 and 2009. All the patients took an echo and catheterization as an integral part of pre-heart transplant. Mean age was 45.5 years old, 68 (75.6%) male. Fourty-two (46.7%) were Chagas' disease patients, 32 (35.6%) presented idiopathic dilated cardiomyopathy, 10 (11.1%) had ischemic cardyomiopathy. RESULTS: The mean eco-PASP was 45 ± 12mmHg). The mean cat-PASP was 47 ±14mmHg. The eco-PASP-Chagas was 41.7 ±12,5 mmHg and non-Chagas 47.6 ±12.8 mmHg P=0.04. The cat-PASP-Chagas was 46 ±12.1 mmHg and non-Chagas 48.7 ±12.8 mmHg P=0.43. Eight patients had cat-PASP>60. The correlation between eco-PASP and cat-PASP in Chagas' patients was r=0.45; P=0.008 and in the non-Chagas was r=0.66; P<0.001. The eco-PASP-Chagas>32,5mmHg has a sensitivity of 79% and specificity of 75% to diagnose PH, with an area under the curve of 0.819. The eco-PASP-non-Chagas>35.5 mmHg has a sensitivity of 82% and a specificity of 70% to diagnose PH, with an area under the curve of 0.776. CONCLUSIONS: There is a good correlation between eco-PASP and cat-PASP (r=0.54) in pre-heart transplant patients. The eco-PASP was lower in the Chagas' group. The echocardiogram is an important method to diagnosis and control pulmonary pressure in pre-heart transplant, specifically in Chagas' patients. The catheterization is still important to evaluate pulmonary reactivity during vasodilation test.
Subject(s)
Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Young Adult , Chagas Disease , Echocardiography, Doppler/methods , Heart Transplantation , Cardiac Catheterization/methods , Hypertension, Pulmonary/diagnosis , Pulmonary Artery , Waiting Lists , Epidemiologic Methods , Hemodynamics/physiology , Hypertension, Pulmonary , Preoperative Care , Pulmonary Artery/physiopathologyABSTRACT
Objective Artificial atrial septum defect combining pulmonary artery banding to create a model of congenital heart defect with decreased pulmonary blood flow to explore the morphological changes of immature pulmonary vascular. Methods Choose twenty piglets with about one to two-month-old, which are exclusively for experiment used. The piglets were randomly divided into three groups: normal control group (group C, n = 6), Small incisions on the right chest, produced a transient reduction in pulmonary blood; low-medium pulmonary artery stenosis groups ( group T1, n = 7 ) : Did artificial room septostomy creation by self-dilators which were delivered into the surface of the right atrium and controlled Systolic trans pulmonary artery banding pressure (Trans-PABP) at pressure of 20 - 30 mmHg; severe pulmonary artery stenosis groups ( group T2, n = 7): T2 were the same surgical procedures with group T1 ,and controlled Trans-PABP ≥ 30 -50 mmHg. Monitored ultrasound after operation , carried out 64-slice computed tomography scanning after one month, to measure the proximal vessel diameter and TransPABP , after two month surgical exploration on the left chest. When the animals were sacrificed, the heart and lung tissue was cut to measure atrial septal defect, pulmonary artery and the banding diameter. By weihgt elastic fiber and van Cieson staining to observe the morphological pathological changes, three groups took lung tissue with right middle lobe lateral segment about 1.0 cm × 0.8 cm × 0.8cm at the end of surgery and 2-months after operation respectively. Results The models were all successfully in the survival animal of the two test groups. One pig died from tracheal intubation accident in the C group, there was one case died due to bowel obstruction in the T1 group, And there were two cases died result from acute right heart failure and chronic heart failure respectively in T2 group. 64-slice CT angiography showed that BD was significantly lower than the AOD in the two test groups, the proximal pulmonary vascular expansion result from stenosis, distal pulmonary vascular scarce. Histopathology showed that the pulmonary artery inside diameter of T1 and T2 was significantly higher than group C(P ＜0. 05,P ＜ 0.01), and the NAPSC of two experimental groups were significantly lower than group C 2-month after operation( P ＜0.01).Conclusion This type of Piglet model is closer to clinical pathological and physiological ,64-slice spiral CT combined with lung histopathology observed for the evaluation of pulmonary vascular hypoplasia is a reliable method. Tunica media of pulmonary arterioles hypoplasia with the number reducing, with pulmonary artery banding increased,the degree of pulmonary arterioles hypoplasia gradually increased.