ABSTRACT
The 2015 European Guidelines on Diagnosis and Treatment of Pulmonary Hypertension are also valid for Germany. The guidelines contain detailed recommendations for the targeted treatment of pulmonary arterial hypertension (PAH). However, the practical implementation of the European Guidelines in Germany requires the consideration of several country-specific issues and already existing novel data. This requires a detailed commentary to the guidelines, and in some aspects an update already appears necessary. In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany. This conference aimed to solve practical and controversial issues surrounding the implementation of the European Guidelines in Germany. To this end, a number of working groups was initiated, one of which was specifically dedicated to the management of decompensated right heart failure, intensive care management and perioperative management in patients with pulmonary hypertension. This article summarizes the results and recommendations of the working group on decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension.
Subject(s)
Cardiology/standards , Hypertension, Pulmonary/surgery , Monitoring, Intraoperative/standards , Practice Guidelines as Topic , Pulmonary Medicine/standards , Ventricular Dysfunction, Right/prevention & control , Germany , Humans , Hypertension, Pulmonary/complications , Hypertension, Pulmonary/diagnosis , Ventricular Dysfunction, Right/diagnosis , Ventricular Dysfunction, Right/etiologyABSTRACT
The 2015 European Guidelines on Pulmonary Hypertension did not cover only pulmonary arterial hypertension (PAH), but also other significant subgroups of pulmonary hypertension (PH). In June 2016, a Consensus Conference organized by the PH working groups of the German Society of Cardiology (DGK), the German Society of Respiratory Medicine (DGP) and the German Society of Pediatric Cardiology (DGPK) was held in Cologne, Germany to discuss open and controversial issues surrounding the practical implementation of the European Guidelines. Several working groups were initiated, one of which was dedicated to the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). In every patient with PH of unknown cause CTEPH should be excluded. The primary treatment option is surgical pulmonary endarterectomy (PEA) in a specialized multidisciplinary CTEPH center. Inoperable patients or patients with persistent or recurrent CTEPH after PEA are candidates for targeted drug therapy. For balloon pulmonary angioplasty (BPA), there is currently only limited experience. This option - as PEA - is reserved to specialized centers with expertise for this treatment method. In addition, a brief overview is given on pulmonary artery sarcoma, since its surgical treatment is often analogous to PEA. The recommendations of this working group are summarized in the present paper.
Subject(s)
Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/therapy , Practice Guidelines as Topic , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Pulmonary Medicine/standards , Antihypertensive Agents/administration & dosage , Cardiology/standards , Drug Therapy, Combination/standards , Fibrinolytic Agents/administration & dosage , Humans , Hypertension, Pulmonary/etiology , Molecular Targeted Therapy/standards , Pulmonary Embolism/complicationsABSTRACT
Acute or chronic right ventricular failure is an often misdiagnosed cause of cardiopulmonary insufficiency. In addition to clinical symptoms or laboratory testing, echocardiography and invasive hemodynamic measurement by means of right-heart catheterization are essential for diagnosis and treatment control. In case of acute right ventricular failure, adequate symptomatic treatment of the life-threatening situation is important. Main issues are maintenance of coronary artery perfusion pressure and myocardial oxygen delivery as well as reduction of right ventricular afterload. In persistent right ventricular failure extracorporeal or intracorporeal assist devices are increasingly used as bridging or destination therapy. On a long-term basis, the targeted therapy of the underlying disease is crucial.
Subject(s)
Critical Care , Ventricular Dysfunction, Right/therapy , Acute Disease , Cardiac Catheterization , Chronic Disease , Diagnosis, Differential , Echocardiography , Extracorporeal Membrane Oxygenation , Heart-Assist Devices , Hemodynamics/physiology , Magnetic Resonance Imaging , Ventricular Dysfunction, Right/etiology , Ventricular Dysfunction, Right/physiopathologySubject(s)
Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/therapy , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Angioplasty, Balloon , Anticoagulants/administration & dosage , Chronic Disease , Endarterectomy , Follow-Up Studies , Humans , Hypertension, Pulmonary/mortality , Long-Term Care , Pulmonary Embolism/mortality , Survival RateABSTRACT
This position paper summarises current developments in chronic thromboembolic pulmonary hypertension (CTEPH) including diagnostic approaches and treatment options. Based on the guidelines of the task force of CTEPH experts at the 5th World Symposium on Pulmonary Hypertension in Nice 2013. Open questions arising during the treatment of patients with CTEPH are addressed. Patients with suspected CTEPH should undergo echocardiography and cardiopulmonary exercise testing. A ventilation/perfusion scan is the recommended imaging test for screening in the diagnostic algorithm for the evaluation of CTEPH. CTEPH-patients should be discussed in an expert center with an interdisciplinary team and an experienced PEA surgeon to decide the further treatment. Pulmonary endarterectomy (PEA) is the treatment of choice for patients with CTEPH. Medical therapy with PH-targeted medications for inoperable CTEPH and residual disease after PEA should only be initiated if evaluation reveals that the patient is no candidate for a PEA. Current data suggest that CTEPH patients treated with PEA have a better long-term survival rate and quality of life than patients treated with medical therapy.
Subject(s)
Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/therapy , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Algorithms , Chronic Disease , Combined Modality Therapy , Cooperative Behavior , Echocardiography , Endarterectomy , Exercise Test , Humans , Hypertension, Pulmonary/mortality , Hypertension, Pulmonary/physiopathology , Interdisciplinary Communication , Mass Screening , Molecular Targeted Therapy , Practice Guidelines as Topic , Prognosis , Pulmonary Artery , Pulmonary Embolism/mortality , Pulmonary Embolism/physiopathology , Survival Rate , Tertiary Care Centers , Ventilation-Perfusion Ratio/physiologyABSTRACT
Right-sided heart failure is a severe and often life-threatening complication of chronic pulmonary hypertension. The detection of trigger factors that induce right heart failure in previously stable patients is important to initiate a causal therapeutic strategy. Pulmonary embolism (PE) is a frequent cause of acute right heart failure and therapeutic strategies for PE are well documented in the current guidelines. Treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH) is surgical pulmonary endarterectomy (PEA) and patients with possible CTEPH should be referred to an experienced PEA surgeon without delay. Intensive care management for overt right heart failure is complex and includes the use of pulmonary vasodilators, individual adjustment of diuretic or volume therapy, augmentation of myocardial contractility and left ventricular afterload. Therapeutic regimens aim at optimized filling of the right ventricle, improvement of myocardial perfusion by avoiding tachycardia, elevating systemic pressure and reducing right ventricular afterload. Early communication with a specialized center for pulmonary hypertension is recommended.
Subject(s)
Critical Care/methods , Heart Failure/diagnosis , Heart Failure/therapy , Hypertension, Pulmonary/diagnosis , Pulmonary Embolism/diagnosis , Pulmonary Embolism/therapy , Heart Failure/etiology , Humans , Hypertension, Pulmonary/complications , Hypertension, Pulmonary/therapy , Pulmonary Embolism/complications , Treatment OutcomeABSTRACT
In the 2009 European Guidelines on pulmonary hypertension one section covers aspects of pathophysiology, diagnosis and treatment of chronic thromboembolic pulmonary hypertension (CTEPH). The practical implementation of the guidelines for this disease is of crucial importance, because CTEPH is a form of pulmonary hypertension which can be surgically cured. It is, however, frequently diagnosed late in the course of disease and often treated not correctly. In the European Guidelines CTEPH is addressed relatively briefly, although it is a common form of PH which is often overlooked. Any patient with unexplained PH should be evaluated for the presence of CTEPH. A ventilation/perfusion lung scan is recommended as the first step to exclude CTEPH. If the ventilation/perfusion lung scan or multislice CT angiography reveals perfusions defects suggesting the diagnosis of CTEPH, the patient should be referred to a centre with expertise in the medical and surgical management of these patients. After diagnosis of CTEPH the case has to be reviewed by an experienced surgeon in a PEA centre for assessment of operability. The recommendations of the European guidelines are summarized in the current manuscript with additional comments regarding diagnosis and treatment according to most recent evidence.
Subject(s)
Hypertension, Pulmonary/physiopathology , Pulmonary Embolism/physiopathology , Angiography , Chronic Disease , Delayed Diagnosis , Germany , Hemodynamics/physiology , Humans , Hypertension, Pulmonary/diagnosis , Hypertension, Pulmonary/surgery , Prognosis , Pulmonary Embolism/diagnosis , Pulmonary Embolism/surgery , Tomography, Spiral Computed , Ventilation-Perfusion Ratio/physiologyABSTRACT
In order to cope with increasing demands to supply information to a variety of documentation systems outside pathology, pathologists need to set standards both for the content and the use of the information they generate. Oncological datasets based on a set vocabulary are urgently required for use both in pathology and in further processing. Data elements were defined according to German pathology report guidelines for colorectal cancers in line with ISO 11179 requirements for the relations between data element concepts and value domains, as well as for further formal conditions, which can be exported in XML together with metadata information. Tests on 100 conventionally written diagnoses showed their principal usability and an increasing degree of guideline conformity in diagnoses commensurate with training time. This set of oncological data elements is a valuable checklist tool for pathologists, enabling formatted information export for further use and saving documentation effort.
Subject(s)
Documentation/standards , Electronic Health Records/organization & administration , Information Management/organization & administration , Neoplasms/pathology , Checklist , Colorectal Neoplasms/pathology , Cooperative Behavior , Guideline Adherence , Humans , Interdisciplinary Communication , Neoplasms/classification , Patient Care Team , Programming Languages , Terminology as TopicABSTRACT
HISTORY AND CLINICAL FINDINGS: A 53-year-old man was admitted because of anuria, dyspnea and a septic temperature. The patients' history included chronic alcoholism, chronic pancreatitis, COPD and a right nephrectomy because of nephrolithiasis. Urosepsis was initially suspected. INVESTIGATIONS: The patients' clinical condition and nutritional state were severely reduced. Laboratory findings revealed severe systemic inflammation (leucocyte count: 22.4/nl, CRP: 324 mg/l). Computed tomography showed a large left-sided pleural effusion, encapsulated abdominal fluid below the diaphragm and alongside the pancreatic tail. After aspiration of the pleural effusion the diagnosis of an exsudate with elevated concentration of lipase (56,000 U/l) was confirmed. Endoscopic ultrasound showed a 3-4 cm pseudocystic mass originating in the region of the pancreatic tail. The ERP depicted chronic pancreatitis with strictures and destruction of the pancreatic duct. Two fistulae were identified, one proximal to a ductal stricture in the pancreatic head and a second one in the pancreatic tail which corresponded to the reported pseudocyst. TREATMENT AND CLINICAL COURSE: The patient was admitted to the ICU with symptoms of impending sepsis. The pleural effusion was treated with CT-guided chest drainage. The initial endoscopic attempt at stent closure of the fistula failed because it was possible to pass through the ductal stricture only with a thin hydrophilic wire and small-lumen catheter. However, injection of fibrin glue into the proximal pancreatic duct over a length of 2 cm obliterated the fistula and the pleural effusion was resolved. CONCLUSION: Pancreatic-pleural or pancreatic-mediastinal fistula is a rare complication of pancreatitis associated with unilateral pleural effusion. Combined internal endoscopic drainage and external chest drainage is the treatment of choice. After failure of routine endoscopic therapy, endoscopic closure of fistulas using fibrin glue might offer an alternative treatment strategy.
Subject(s)
Mediastinal Diseases/therapy , Pancreatic Fistula/therapy , Pancreatitis, Chronic/complications , Pleural Effusion/etiology , Pleural Effusion/therapy , Drainage/methods , Endoscopy, Digestive System , Fibrin Tissue Adhesive/administration & dosage , Humans , Male , Mediastinal Diseases/complications , Mediastinal Diseases/diagnostic imaging , Middle Aged , Pancreatic Ducts , Pancreatic Fistula/complications , Pancreatic Fistula/diagnostic imaging , Pancreatic Pseudocyst/diagnostic imaging , Pleural Effusion/diagnostic imaging , Tissue Adhesives/administration & dosage , Tomography, X-Ray Computed , UltrasonographyABSTRACT
Stromal tumor of the prostate of uncertain malignant potential (STUMP) is an extremely rare entity. The clinical symptoms are nonspecific for this tumor. An abnormal digital rectal examination or an elevated prostate-specific antigen level is possible but not obligatory. The tumor has a high recurrence rate and could develop a sarcomatous dedifferentiation. Therapy varies from a wait-and-see approach to a radical prostatectomy. We report the case of a 74-year-old patient with a STUMP. Based on the case, the clinical, diagnostic, and therapeutic aspects of this rare tumor are discussed.
Subject(s)
Prostatic Intraepithelial Neoplasia/pathology , Prostatic Neoplasms/pathology , Aged , Diagnosis, Differential , Humans , Male , Rare Diseases/pathology , Stromal Cells/pathologyABSTRACT
PURPOSE: Comparison of two different types of contrast-enhanced 3D-MR angiography (CE-MRA) with integrated parallel acquisition technique (iPAT) in patients with chronic-thromboembolic pulmonary hypertension (CTEPH) and evaluation whether sagittal acquisition with higher resolution and minimized acquisition time is superior to common coronal orientation. MATERIALS AND METHODS: CE-MRA was performed on 15 patients with CTEPH preoperatively and on 10 patients also postoperatively, while 5 other patients received only a postoperative MRA. All 30 MR studies with one coronal and two sagittal acquisitions were blindly evaluated and compared. The resolution of coronal and sagittal MRA was 1.3 x 0.6 x 1.4 mm (3) and 1.2 x 1.2 x 1.2 mm (3), and acquisition time 20 and 17 sec (iPAT factor 2, GRAPPA), respectively. Image quality, coverage of the pulmonary arteries, delineation of patent segmental and sub-segmental vessels and pathological findings were assessed. A total of 1980 vessels were evaluated. RESULTS: Sagittal 3D-MRA was superior in overall image quality and complete coverage of the vessels compared to coronal MRA, 18 % of subsegmental and 4.3 % of segmental arteries as well as 1.1 % of the lobar vessels were not covered by coronal acquisition. Only 0.5 % of sagittal subsegments were missed. The number of depicted patent segmental and subsegmental arteries was higher in sagittal MRA (460 vs 489 and 573 vs 649, respectively), the total difference of patent vessels was 105. Sagittal MRA revealed more pathological findings in segmental arteries (especially thrombotic material and stenoses). CONCLUSION: Sagittal CE-MRA of the pulmonary arteries with higher resolution and short acquisition time proved to be superior in all assessed criterias like image quality, vessel coverage, depiction of patent peripheral arteries and pathological findings compared to coronal MRA. The applied sagittal MRA is recommended for the routine practise in diagnostic evaluation of patients with CTEPH.
Subject(s)
Hypertension, Pulmonary/diagnosis , Magnetic Resonance Angiography , Pulmonary Artery , Pulmonary Embolism/diagnosis , Chronic Disease , Contrast Media , Female , Gadolinium DTPA , Humans , Imaging, Three-Dimensional , Magnetic Resonance Angiography/methods , Male , Middle Aged , Postoperative Period , Pulmonary Embolism/surgeryABSTRACT
PURPOSE: To evaluate the potential of MRI to grade cardiac impairment and pulmonary hypertension in patients with chronic thromboembolic pulmonary hypertension (CTEPH) in comparison with invasive pressure measurements before and after surgery. MATERIALS AND METHODS: We examined 35 patients with CTEPH before and after pulmonary thromboendarterectomy (PTE). For assessment of hemodynamics, velocity-encoded segmented GE-sequences (pulmonary arteries and ascending aorta) and segmented cine GE-sequences along the short axis of the heart were performed. The analysis comprised calculation of ejection fractions, peak velocities, mean pulmonary arterial flow and vessel diameter. 10 volunteers served as controls. Flow measurements were compared to invasively measured mean pulmonary arterial pressure (MPAP) and vascular resistance (PVR). RESULTS: Compared to volunteers, CTEPH-patients showed significantly reduced right ventricular ejection fractions (p < 0.001), pulmonary peak velocity (p < 0.001) and significantly increased diameters of the pulmonary arteries (p < 0.001). The flow measurements in the aorta (2713 ml/min) and the pulmonary arteries (2088 ml/min) revealed a large bronchopulmonary shunt. After PTE, there was a significant reduction in vessel diameter (p < 0.001). This was associated with a significant increase in pulmonary peak velocities (p < 0.001). The increase in pulmonary peak velocities correlated with the decrease of PVR (r = 0.5) and MPAP (r = 0.6). The ejection fraction of the right ventricle correlated with PVR (r = 0.6) and MPAP (r = 0.7). The postoperative decrease in MPAP correlated with the increase in right ventricular ejection fraction (r = 0.8). After PTE there was no bronchopulmonary shunt volume. All patients had an inverse motion of the interventricular septum. It returned to normal in 68 % of patients after surgery. CONCLUSION: Breath-hold MR-techniques enable non-invasive assessment of pulmonary hemodynamics in patients with CTEPH. For postoperative follow-up studies MRI could be considered the modality of choice.
Subject(s)
Endarterectomy , Hemodynamics , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/surgery , Magnetic Resonance Imaging, Cine , Magnetic Resonance Imaging , Pulmonary Embolism/physiopathology , Pulmonary Embolism/surgery , Adult , Aged , Blood Pressure , Cardiac Catheterization , Child , Chronic Disease , Data Interpretation, Statistical , Electrocardiography , Female , Follow-Up Studies , Humans , Magnetic Resonance Imaging/methods , Magnetic Resonance Imaging, Cine/methods , Middle Aged , Postoperative Period , Pulmonary Artery/physiology , Pulmonary Circulation , Stroke Volume , Treatment Outcome , Vascular ResistanceABSTRACT
AIMS: Evaluation of a three-dimensional reconstruction method to show the changes of right ventricular volume and systolic function when patients undergo pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. METHODS AND RESULTS: In the examination of 11 patients (four female, seven male; age 56+/-10 years) before and after pulmonary thromboendarterectomy, end-diastolic and end-systolic right ventricular volumes were determined as a sum total of the calculated volumes of derived parallel slices of the right ventricle. Using a Tomtec workstation and a Vingmed CFM 800 echocardiography device, the acquired data were ECG-and respiration-triggered in the course of transthoracic examination, using step intervals of 5 degrees. The ventricular outline was traced manually on 5mm slices from longitudinal cut planes. For subsequent correction, their area measurements were displayed and the volume cross-checked against the volume from orthogonal cut planes. End-diastolic and end-systolic volumes could be quantified in 11/11 cases before surgery, but data could only be attained for 9/11 patients after surgery, because a limited apical window rendered the postoperative three-dimensional reconstruction impossible in two cases. Before surgery, right ventricular size was larger than normal and systolic function was clearly impaired in all of the patients (end-diastolic volume: 121+/-37 ml; end-systolic volume 91+/-30 ml; ejection fraction 25+/-8%). The decrease in mean pulmonary artery pressure after surgery was significant (47+/-8 vs 26+/-8 mmHg; P<0.05). End-diastolic and end-systolic right ventricular volumes had been reduced (80+/-33 ml and 54+/-31 ml respectively), and the ejection fraction had increased (36+/-9%). CONCLUSIONS: Successfully performed pulmonary thromboendarterectomy leads to a significant reduction of right ventricular chamber size and improvement of systolic function, which can be determined with great precision and quite easily, using transthoracic three-dimensional echocardiography. Published by Elsevier Science Ltd. All rights reserved.
Subject(s)
Echocardiography, Three-Dimensional , Endarterectomy , Hypertension, Pulmonary/physiopathology , Pulmonary Artery/surgery , Pulmonary Embolism/complications , Ventricular Function, Right , Adult , Aged , Cardiac Volume , Female , Hemodynamics , Humans , Hypertension, Pulmonary/diagnostic imaging , Hypertension, Pulmonary/etiology , Hypertension, Pulmonary/surgery , Male , Middle Aged , Pulmonary Embolism/surgeryABSTRACT
BACKGROUND AND OBJECTIVES: Pulmonary artery sarcoma is a rare neoplasm and possibly unnoticed cause of pulmonary hypertension. The presentation is one of central pulmonary artery obstruction and progressive right-heart failure. In most cases, the diagnosis of malignancy is confirmed post mortem. We report the outcome of eight patients with primary pulmonary artery sarcomas. METHODS: Eight patients (four female, four male, mean age 48,2 years, preop. NYHA functional class III/IV: n = 5/3) were referred for further evaluation of pulmonary hypertension. Malignancy was suspected in six of these patients by means of computed tomography (CT) and magnetic resonance tomography (MRT). In two patients diagnosis was established during pulmonary thromboendarterectomy based on histological examination of frozen sections. Operative procedures consisted of gross tumor resection with prosthetic replacement (n = 3) or reconstruction (n = 5) of central parts of the pulmonary vessels. Additional pneumonectomy was necessary in two patients, resection of metastases in one patient. Seven patients received adjuvant radio- and/or chemotherapy. RESULTS: There were no postoperative deaths. 3 months after surgery, all patients demonstrated improvement in hemodynamics and exercise tolerance. Four patients died 7, 9, 18 and 19 months after surgery, respectively. Two patients are alive 3 and 39 months after primary surgery with evidence of pulmonary metastases. Two patients are alive in complete remission 25 and 65 months postoperatively. CONCLUSIONS: In patients with primary pulmonary artery sarcoma, emphasis must be placed on early identification which can be achieved by CT and MRT. Radical surgical resection currently offers the best chance for survival. Adjuvant therapy might bring additional benefit.
Subject(s)
Hypertension, Pulmonary/etiology , Pulmonary Artery/surgery , Sarcoma/surgery , Vascular Neoplasms/surgery , Adult , Antineoplastic Agents/therapeutic use , Chemotherapy, Adjuvant , Female , Humans , Leiomyosarcoma/complications , Leiomyosarcoma/diagnosis , Leiomyosarcoma/surgery , Magnetic Resonance Imaging , Male , Mesenchymoma/complications , Mesenchymoma/diagnosis , Mesenchymoma/surgery , Middle Aged , Neoplasm Metastasis , Neoplasm Recurrence, Local/pathology , Pneumonectomy , Prognosis , Pulmonary Artery/pathology , Radiotherapy, Adjuvant , Sarcoma/complications , Sarcoma/diagnosis , Tomography, X-Ray Computed , Vascular Neoplasms/complications , Vascular Neoplasms/pathologyABSTRACT
STUDY OBJECTIVES: This study sought to evaluate the pathophysiology of left and right heart failure in patients with chronic thromboembolic pulmonary hypertension (CTEPH) who were hospitalized to undergo pulmonary thromboendarterectomy (PTE). DESIGN: Thirty-nine patients (16 women and 23 men; mean +/- SD age, 55+/-12 years) with severe CTEPH were examined before and 13+/-8 days after PTE by way of transthoracic echocardiography and right heart catheterization. MEASUREMENTS AND RESULTS: Examination results confirmed in all cases that before surgery the right ventricles were enlarged and systolic function was impaired. Moderate to severe tricuspid valve regurgitation was observed. Left ventricular eccentricity indexes reflected a leftward displacement of the interventricular septum. End-diastolic left ventricular size and systolic function had decreased, and the left ventricular filling pattern showed impaired diastolic function. After surgery, mean pulmonary artery pressure was significantly lower (48+/- 10 mm Hg vs. 25+/-7 mm Hg; p<0.05). The calculated end-diastolic and end-systolic right ventricular areas had decreased: 30+/-7 cm(2) vs 21 +/-5 cm(2) (p<0.05) and 24+/-6 cm(2) vs. 14+/-4 cm(2) (p<0.05), respectively. Right ventricular fractional area change had increased (20+/-7% vs. 33+/-8%; p<0.05). Most of the patients exhibited a marked decrease in the severity of tricuspid regurgitation. Septal motion, left ventricular systolic function, and diastolic filling pattern returned to normal values (early to late diastolic left ventricular inflow ratio, 0.70+/-0.33 vs. 1.35+/-0.51; p<0.05). The mean cardiac index also improved (2.7+/-0.6 L/min/m(2) vs. 3.7+/-0.8 L/min/m(2)). CONCLUSIONS: In CTEPH, functions are impaired in the right as well as the left ventricles of the heart. Improved lung perfusion and the reduction of right ventricular pressure overload are direct results of PTE, which in turn bring a profound reduction of right ventricular size and a recovery of systolic function. Normalization of interventricular septal motion as well as improved venous return to the left atrium lead to a normalization of left ventricular diastolic and systolic function, and the cardiac index improves.
Subject(s)
Endarterectomy , Hypertension, Pulmonary/complications , Pulmonary Embolism/surgery , Thrombectomy/methods , Ventricular Dysfunction, Left/physiopathology , Ventricular Dysfunction, Right/physiopathology , Ventricular Function/physiology , Adult , Aged , Chronic Disease , Echocardiography, Doppler , Female , Humans , Hypertension, Pulmonary/physiopathology , Hypertension, Pulmonary/surgery , Male , Middle Aged , Myocardial Contraction , Postoperative Period , Prospective Studies , Pulmonary Embolism/complications , Pulmonary Embolism/physiopathology , Pulmonary Wedge Pressure , Ventricular Dysfunction, Left/diagnostic imaging , Ventricular Dysfunction, Left/etiology , Ventricular Dysfunction, Right/diagnostic imaging , Ventricular Dysfunction, Right/etiologyABSTRACT
Solitary fibrous tumors of the pleura are rare tumors with unpredictable clinical behaviour. We report about two patients with an incidental finding of an intrathoracic tumor. Preoperative diagnosis was uncertain. In both patients, a solid tumor of the pleura was resected en bloc in combination with a wedge resection of the lung following anterolateral thoracotomy. The postoperative course was eventful. Six months after primary complete resection there were no signs of tumor recurrence.
Subject(s)
Fibroma/diagnosis , Pleural Neoplasms/diagnosis , Diagnosis, Differential , Fibroma/pathology , Fibroma/surgery , Humans , Magnetic Resonance Imaging , Male , Middle Aged , Pleura/pathology , Pleura/surgery , Pleural Neoplasms/pathology , Pleural Neoplasms/surgery , Tomography, X-Ray ComputedABSTRACT
OBJECTIVE: In patients with chronic thromboembolic pulmonary hypertension, pulmonary vascular resistance (PVR) can be reduced by pulmonary thromboendarterectomy (PTE). In this study, long-term symptomatic and hemodynamic effects were investigated. METHODS: Twenty-two patients (12 female, 10 male, mean age 40 years, preoperative NYHA functional class II/III/IV: n = 1/12/9) were re-evaluated 48-72 months (mean 60 months) after surgery. In addition to clinical assessment, radiologic, hemodynamic and echocardiographic investigations were performed. RESULTS: All patients reported a marked improvement of their clinical condition. At follow-up, 11 patients were identified as NYHA class I, 10 as NYHA class II and one patient was in class III. PVR and mean pulmonary artery pressure (mPAP) were significantly reduced (preoperative PVR 800+/-274 dynes/s per cm(-5), follow-up PVR 180+/-28.3 dynes/s per cm(-5); P < 0.001; preoperative mPAP 48.5+/-7.4 mmHg, follow-up mPAP 27.5+/-4.9 mmHg; P < 0.001). There was also a significant increase in arterial blood oxygen tension (preoperative PaO2 59+/-10 mmHg; follow-up PaO2 84+/-12 mmHg; P < 0.001). Chest roentgenograms and echocardiographic examinations revealed significantly decreased right heart dimensions and a recovery of right heart function. CONCLUSION: In patients with severe chronic thromboembolic pulmonary hypertension, persistent symptomatic and hemodynamic improvements can be achieved by PTE.
Subject(s)
Endarterectomy/methods , Pulmonary Embolism/surgery , Adult , Aged , Chronic Disease , Endarterectomy/mortality , Evaluation Studies as Topic , Female , Follow-Up Studies , Hemodynamics , Humans , Male , Middle Aged , Pulmonary Embolism/diagnostic imaging , Pulmonary Embolism/mortality , Pulmonary Embolism/physiopathology , Radiography , Respiratory Function Tests , Survival Rate , Treatment OutcomeABSTRACT
Intimal sarcoma of the pulmonary artery is an extremely rare type of malignant tumor of the large vessels. Despite systematic diagnostics, distinguishing between pulmonary emboli and tumors is difficult. We report a patient who was referred because of suspected embolic occlusion of the pulmonary artery. The operation was started with the intention of performing a pulmonary artery thromboendarterectomy; however, intraoperative histology revealed a malignant mesenchymal tumor. Therefore, the left lung was resected with the use of extracorporeal circulation, and the pulmonary trunk and right pulmonary artery were reconstructed. A solitary right lung metastasis was resected 3 months later using stapling devices. Complete surgical resection is the treatment of choice for patients with sarcoma of the pulmonary arteries. Surgical therapy often includes extensive reconstructive measures. Since, thromboembolic obstruction cannot be excluded preoperatively, patients with this type of disease should be treated at centers experienced with the broad spectrum of pulmonary artery surgery.
ABSTRACT
Pulmonary thromboendarterectomy is an accepted operative procedure for treatment of pulmonary hypertension due to chronic embolism. Despite its proven value this procedure has been established at very few centers worldwide. In this paper we report our actual operative concept and operative results. Between 8'89 and 4'96 127 patients were operated with use of extracorporeal circulation, deep hypothermia and circulatory arrest. After analysis of the initial high perioperative mortality (26%, 29/108) our operative and postoperative concept changed since 11'94: 1. central incision of both pulmonary arteries, 2. endarterectomy exclusively during circulatory arrest, 3. prolonged reperfusion to 37 degrees C, 4. pressure controlled ventilation, NO-inhalation, early extubation, and 5. modified vasopressor therapy. Preoperatively 12 of the 19 patients were in NYHA class III and 6 in class IV. Mean pulmonary artery pressure was 52(17) mmHg with a calculated pulmonary resistance of 1013(579) dynes.s.cm-5. Mean circulatory arrest time was 37 min (19-57 min) (bypass time 345 min, (240-430 min)). Perioperatively two patients (11%) died (multiorgan failure; rethrombosis of pulmonary artery/right heart failure), all other patients survived (89%). Perioperative complications included reversible renal failure, delirium and postcardiotomy syndrome (1/2/1). Mean pulmonary resistance was postoperatively significantly reduced (362(124) dynes.s.cm-5) (p < 0.01). Early results of pulmonary thromboendarterectomy can be improved by consequent modifications of the intra- and postoperative concept.
