patient with chronic pe treatment options - dr szymon darocha
TRANSCRIPT
Patient with chronic PE for endovascular or surgical recanalization of PA?
Szymon [email protected]
Department of Pulmonary Circulation and Thromboembolic DiseasesCenter of Postgraduate Medical EducationEuropean Helth Center Otwock
CASE REPORT
Female:- 52 y.o.- 15.10.2007 – Acute PE- DVT (-)- III functional class- AVK thetapy untill 2014r. without improvement.
Before BPA
Functional class III
6MWT [m] 331
NT-proBNP [pg/ml] 228
PVR [j.W.] 6,7
mPAP [mmHg] 50
mRAP [mmHg] 11
PCWP [mmHg] 13
CI [l/min*m2] 3,33
- diagnosis of CTEPH ,
- consulting cardiosurgeon: non-operable,
ETIOPATHOGENESIS
ACUTE PE
Resolution of thromboemboli
Post-thromboembolic residua without
resting precapillary PH
Post-thromboembolic residua with resting
precapillary PH = CTEPH
0,5 – 4%/1 year
DEFINITION OF CTEPH
1. Symptomatic PH,
2. Heamodynamic measurements:
- mPAP≥25mmHg,
- PAWP≤15mmHg,
3. Chronic/organized thrombi/emboli in the pulmonary arteries (main, lobar, segmental, subsegmental),
4. After at least 3 months of effectiveanticoagulation.
PROGNOSIS FOR CTEPH
Riedel et al, Chest 1982; 81: 151Lewczuk et al, Chest 2001; 119: 818
mPAP
PULMONARY ENDARTERECTOMY
Courtesy prof. Andrzej Biederman, Warsaw - WilanówCTEPH
Acute PE
Post-thrombotic deposits
non-operable – 43,2%
persistent CTEPH – 16,7%
Mayer et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011;141:702–710.
Medical trials for CTEPH
CHEST-2
8 weeks
Long-term open-label
phase at chronic dose
up to 2.5 mg
tid, three times daily.
Study design
CHEST-1
Titration
8 weeks
Maintenance
8 weeks
Randomizationmultiple
Riociguatup to 2.5 mg tid
Sham titration2
Titrate up to 2.5 mg tid
Placebo1
24-week blinded phase
Analysis of primary and
secondary endpoints at Week 16
RIOCIGUAT PHASE 3 STUDIES: CHEST-1
Ghofrani HA, et al. N Engl J Med 2013;369:319-29
N=261
6MWD, 6-minute walking distance; PEA, pulmonary endarterectomy.
Improvement demonstratedacross inoperable and postoperative patients
RIOCIGUAT PHASE 3 STUDIES: CHEST-1
Primary endpoint: entire population(n=173/88)
+46 mp<0.0001
(95% CI: 25–67 m)
Population with persistent/recurrent PH after PEA (n=52/20)
Inoperable population (n=121/68)
+27 m (95% CI: -10–63 m)
+54 m(95% CI: 29–79 m)
-20
-10
0
10
20
30
40
50
60
Riociguat
Placebo
-20
-10
0
10
20
30
40
50
60Riociguat
Placebo
-20
-10
0
10
20
30
40
50
60
Me
an c
han
ge f
rom
bas
elin
e
in 6
MW
D (
m)
Riociguat
Placebo
Ghofrani HA, et al. N Engl J Med 2013;369:319-29
CHEST-1: Riociguat significantly improved PVR
-300
-250
-200
-150
-100
-50
0
50
100
Me
an c
han
ge f
rom
b
ase
line
in P
VR
±SE
M
(dyn
∙s∙c
m-5
)
Riociguat (n=151)
Placebo (n=82)
−246 dyn∙s∙cm–5
p<0.0001(95% CI: −303 to −190 dyn∙s∙cm–5)
Bars represent mean change from baseline (±SEM)LS mean treatment effect taken from ANCOVA
RIOCIGUAT PHASE 3 STUDIES: CHEST-1
experimental
Andreassen AK, Ragnarsson A, Gude E, et al. Heart 2013;99:1415– 1420
n = 20
18,6 BPA`s/pat.
73 sessions
3,7 sessions/pt
ANGIOSCOPY
Images obtained during angioscopy in chronic thromboembolic pulmonary hypertension (a–c) and normal bifurcation of pulmonary artery (d).
www.springerimages.com
OCT
Sugimura K. 2011
Our first experience with BPA• A 43-year-old female with CTEPH• disqualified from pulmonary endarterectomy. • treated with sildenafil (off-label) for one year without improvement. • BPA of two subsegmental arteries was performed
mPAP 56 mmHg, CO 6,03 l/min, PVR 7,96 Wood units
mPAP 47mmHg, CO 5,99 l/min, PVR 6,51 Wood units
mPAP 36mmHg, PVR 4,5 Wood units
At 3 months
n Age Sex N of sessions N of segments Main complication
1. 43 F 2 4 -
2. 23 F 2 8 SVT
3. 71 F 2 6 Reperfusion oedema, haemopthysis,
4. 66 M 1 2 Hemoptysis
5. 56 F 2 3 Subcutaneus hematoma, perforation
6. 47 F 2 6 cough
7. 76 M 1 3 -
8. 66 F 1 2 -
9. 70 F 1 2 Reperfusion oedema, haemoptysis
10. 55 F 1 3 Perforation
11. 66 M 1 3 -
12. 65 F 1 4 Reperfusion oedema, haemopthysis, cough
13. 28 M 1 4 Death (reperfusion oedema)
14. 62 M 1 3 Perforation, cough
15. 33 M 1 4 Desaturation
(20) (57)
Thank you