Diagnosis of chronic thromboembolic pulmonary hypertension: A Canadian Thoracic Society clinical practice guideline update

Helmersen, Doug; Provencher, Steeve; Hirsch, Andrew; Dam, A. A. van; Dennie, Carole; Perrot, Marc de; Mielniczuk, Lisa; Hirani, Naushad; Chandy, George; Swiston, John R.; Lien, Dale; Kim, Nick H.; Delcroix, Marion; Mehta, Sanjay

doi:10.1080/24745332.2019.1631663

Cited by 20 publications

(14 citation statements)

References 78 publications

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“…The ESC/ERS guidelines recommend against routine echocardiography in all PE survivors because of the low yield and to prevent overdiagnosis [92]. Similarly, the Canadian Thoracic Society (CTS), after a formal clinical practice guideline development process, involving systematic literature searches and evaluation of the evidence according to GRADE approach, recommended against routine screening after acute PE [113]. In patients with persistent or new onset dyspnoea after PE, the diagnostic work-up starts with echocardiography, followed by VQ scintigraphy and RHC with pulmonary angiography [1], as discussed in section 2.…”

Section: Which Pe Patients Should Be Systematically Assessed For the ...mentioning

confidence: 99%

ERS statement on chronic thromboembolic pulmonary hypertension

Delcroix

Torbicki²,

Gopalan

et al. 2022

Pulʹmonologiâ (Mosk.)

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Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of acute pulmonary embolism, either symptomatic or not. The occlusion of proximal pulmonary arteries by fibrotic intravascular material, in combination with a secondary microvasculopathy of vessels < 500 μm, leads to increased pulmonary vascular resistance and progressive right heart failure. The mechanism responsible for the transformation of red clots into fibrotic material remnants has not yet been elucidated. In patients with pulmonary hypertension, the diagnosis is suspected when a ventilation/ perfusion lung scan shows mismatched perfusion defects, and confirmed by right heart catheterisation and vascular imaging. Today, in addition to lifelong anticoagulation, treatment modalities include surgery, angioplasty and medical treatment according to the localisation and characteristics of the lesions. This statement outlines a review of the literature and current practice concerning diagnosis and management of CTEPH. It covers the definitions, diagnosis, epidemiology, follow-up after acute pulmonary embolism, pathophysiology, treatment by pulmonary endarterectomy, balloon pulmonary angioplasty, drugs and their combination, rehabilitation and new lines of research in CTEPH. It represents the first collaboration of the European Respiratory Society, the International CTEPH Association and the European Reference Network-Lung in the pulmonary hypertension domain. The statement summarises current knowledge, but does not make formal recommendations for clinical practice.

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Section: Which Pe Patients Should Be Systematically Assessed For the ...mentioning

confidence: 99%

ERS statement on chronic thromboembolic pulmonary hypertension

Delcroix

Torbicki²,

Gopalan

et al. 2022

Pulʹmonologiâ (Mosk.)

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“…92 Besides risk factors for CTEPH, the 2019 Canadian Thoracic Society Guideline on CTEPH has also selected the following groups warranting closer follow-up after acute PE: patients with clues to the presence of CTEPH at the time of acute PE diagnosis or those with unexplained dyspnea despite adequate anticoagulant treatment. 93 Notably, a preserved RV function might give rise to a false-negative echocardiography result, particularly in patients with mild CTEPH. 67 If echocardiography does not show signs of PH, CPET is the next test of choice to quantify exercise limitation and differentiate between different underlying mechanisms, followed by pulmonary perfusion imaging and/or PFTs dependent on CPET results.…”

Section: Optimal Diagnostic Approach Of Persistent Dyspnea After Acutmentioning

confidence: 99%

Determinants and Management of the Post–Pulmonary Embolism Syndrome

Boon

Huisman

Klok

2021

Semin Respir Crit Care Med

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Acute pulmonary embolism (PE) is not only a serious and potentially life-threatening disease in the acute phase, in recent years it has become evident that it may also have a major impact on a patient's daily life in the long run. Persistent dyspnea and impaired functional status are common, occurring in up to 50% of PE survivors, and have been termed the post-PE syndrome (PPES). Chronic thromboembolic pulmonary hypertension is the most feared cause of post-PE dyspnea. When pulmonary hypertension is ruled out, cardiopulmonary exercise testing can play a central role in investigating the potential causes of persistent symptoms, including chronic thromboembolic pulmonary disease or other cardiopulmonary conditions. Alternatively, it is important to realize that post-PE cardiac impairment or post-PE functional limitations, including deconditioning, are present in a large proportion of patients. Health-related quality of life is strongly influenced by PPES, which emphasizes the importance of persistent limitations after an episode of acute PE. In this review, physiological determinants and the diagnostic management of persistent dyspnea after acute PE are elucidated.

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“…Digital subtraction angiography (DSA) has long been considered the gold standard to characterize the involvement of the pulmonary arteries in CTEPH [ 2 , 8 , 9 , 10 ]. In recent years, it is progressively being replaced by CTPA for the diagnosis and assessment of operability [ 9 ].…”

Section: Differential Characteristics Between Diagnostic Selective Segmental Pulmonary Angiography Technique and Central Pulmonary Angiogmentioning

confidence: 99%

“…In recent years, it is progressively being replaced by CTPA for the diagnosis and assessment of operability [ 9 ]. However, a normal CTPA does not rule out CTEPH, since distal segmental or subsegmental involvement may go unnoticed [ 8 , 9 ]. In fact, the publication on “the state of the art in CTEPH” after the last World Symposium in PH in 2018, establishes that, due to the advent of BPA as a therapeutic option in HPTEC, an accurate assessment of very distal vessels of the pulmonary tree is needed.…”

Section: Differential Characteristics Between Diagnostic Selective Segmental Pulmonary Angiography Technique and Central Pulmonary Angiogmentioning

confidence: 99%

Selective Segmental Pulmonary Angiography: Anatomical, Technical and Safety Aspects of a Must-Learn Technique in Times of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Velázquez

Maneiro

Lareo

et al. 2021

JCM

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With the advent of balloon pulmonary angioplasty (BPA) for non-surgical chronic thromboembolic pulmonary hypertension (CTEPH) patients, there is renewed interest in the pulmonary angiography technique. This technique is still the standard imaging modality to confirm CTEPH, which, in addition, helps to determine the most appropriate treatment. Furthermore, learning this technique fulfills two main purposes: to identify BPA candidates and to provide the operator with the catheter handling needed to perform BPA. Operators interested in performing BPA must learn not only the pulmonary arteries’ anatomy, but also which are the best angiographic projections and the most suitable catheters to canalize and display each segmental branch. Unfortunately, this information is scarce in the literature. With this goal, learning the diagnostic pulmonary angiography technique can be a first step on the way to perform BPA. Although there are descriptions on how to perform a pulmonary angiography with balloon-tipped catheters and the digital subtraction technique, this technique does not provide operators with the catheter knowledge and manual skill needed to cannulate each segmental branch. In contrast, learning the conventional selective segmental pulmonary angiography (SSPA) technique provides the operator with this knowledge and skills. In this review, based on the experience of the authors, we describe the pulmonary arteries’ anatomy and detail the practical aspects of the SSPA procedure, with the aim of providing operators with the anatomical and technical knowledge needed to perform BPA. We also summarize the contemporary complications of SSPA in CTEPH patients at a reference center.

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Diagnosis of chronic thromboembolic pulmonary hypertension: A Canadian Thoracic Society clinical practice guideline update

Abstract: Revue canadienne des soins respiratoires et critiques et de la médecine du sommeil

Cited by 20 publications

References 78 publications

ERS statement on chronic thromboembolic pulmonary hypertension

ERS statement on chronic thromboembolic pulmonary hypertension

Determinants and Management of the Post–Pulmonary Embolism Syndrome

Selective Segmental Pulmonary Angiography: Anatomical, Technical and Safety Aspects of a Must-Learn Technique in Times of Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

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