Hemodynamic and ventilatory responses during exercise in chronic thromboembolic disease

Kan, Coen van; Plas, Mart N. van der; Reesink, Herre J.; Steenwijk, Reindert P. van; Kloek, Jaap J.; Tepaske, Robert; Bonta, Peter I.; Bresser, Paul

doi:10.1016/j.jtcvs.2016.05.058

Cited by 76 publications

(61 citation statements)

References 34 publications

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“…Thus, while it is known that patients who develop chronic pulmonary vascular obstruction have significant symptoms,22 our study highlights that exercise limitation may exist even in the absence of chronic imaging abnormalities indicative of vascular compromise. Why baseline imaging parameters, such as abnormal pulmonary artery diameter, appeared to be more prognostic than follow‐up imaging parameters is uncertain, although our study patients had normalization of most imaging parameters by 12 months.…”

Section: Discussionmentioning

confidence: 68%

Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study

Kahn

Akaberi

et al. 2018

Research and Practice in Thrombosis and Haemostasis

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Essentials Exercise Limitation 1 year after an acute pulmonary embolism is common.Serial imaging after acute pulmonary embolism is not well described and how it affects exercise limitation remains unknown.1 year after an acute pulmonary embolism chronic changes are common, more so on perfusion lung scanning than CT pulmonary angiography, but imaging findings did not predict exercise limitation. IntroductionRisk factors for exercise limitation after acute pulmonary embolism (PE) are unknown. As a planned sub‐study of the prospective, multicenter ELOPE (Evaluation of Long‐term Outcomes after PE) Study, we aimed to describe the results of serial imaging by computed tomography pulmonary angiography (CTPA) and perfusion scan during 1 year after a first episode of acute pulmonary embolism, and to assess the association between imaging parameters and exercise limitation at 1 year.MethodsIn a prospective cohort study, 100 patients were recruited between June 2010 and February 2013 at five Canadian university–affiliated hospitals. CT pulmonary angiography was performed at baseline and 12 months, perfusion scan at 6 and 12 months, and cardio‐pulmonary exercise testing at 1 and 12 months. Imaging parameters included: on CT pulmonary angiography, CT obstruction index (CTO) (% clot burden in the pulmonary vasculature), and on perfusion scan, pulmonary vascular obstruction (PVO) (% perfusion defect). Abnormal cardio‐pulmonary exercise test (primary outcome) was defined as percent of predicted peak oxygen uptake (VO2) <80%.ResultsMean (median; SD) CT obstruction index was 28.1% (27.5%; 18.3%) at baseline, 1.2% (0%; 4.3%) at 12 months. Mean (median; SD) pulmonary vascular obstruction was 6.0% (0%; 9.6%) at 6 months, 5.6% (0%; 9.8%) at 12 months. Eighty‐six patients had exercise testing at 12 months, and 46.5% had VO2 < 80% predicted. Mean (median; SD) CT obstruction index at 1 year was similar in patients with percent‐predicted VO2 peak <80% vs >80% on 1‐year cardio‐pulmonary exercise testing (1.4% [0%; 5.7%] vs 1.0% [0%; 2.4%]; P = .70). Mean (SD) pulmonary vascular obstruction at 6 and at 12 months was similar in patients with percent‐predicted VO2 peak <80% vs >80% (6 months: 5.9% [0%; 10.4%] vs 6.2% [4.5%; 9.0%]; P = .91; 12 months: 5.1% [0%; 10.2%] vs 6.0% [0%; 9.7%]; P = .71).ConclusionsImaging findings after pulmonary embolism did not predict exercise limitation. Residual thrombus does not appear to explain long‐term functional limitation after pulmonary embolism.

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Section: Discussionmentioning

confidence: 68%

Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study

Kahn

Akaberi

et al. 2018

Research and Practice in Thrombosis and Haemostasis

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“…Patients with chronic thromboembolic disease with and without pulmonary hypertension show an abnormal pulmonary vascular response to exercise and decreased ventilatory efficiency. PEA is a treatment of choice in surgically accessible CTEPH: responses after PEA point to a restoration of right ventricle stroke volume, ventilatory efficiency and exercise capacity [2,32,33]. Patients with more severely depressed exercise capacity at baseline display a relatively greater degree of functional recovery after PEA.…”

Section: Discussionmentioning

confidence: 99%

Exercise Training After Pulmonary Endarterectomy for Patients with Chronic Thromboembolic Pulmonary Hypertension

Rovere

Pinna

et al. 2018

Respiration

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Background: After undergoing a procedure of pulmonary endarterectomy (PEA), patients with chronic thromboembolic pulmonary hypertension (CTEPH) may still experience reduced exercise capacity. Data on effects of exercise training in these patients are scant. Objectives: To evaluate the effectiveness of exercise training after PEA for CTEPH and if the presence of “residual pulmonary hypertension” may affect the outcome. Methods: Retrospective data analysis of CTEPH patients undergoing inpatient exercise training after PEA. According to predefined criteria, patients were divided into those with (group 1) and without (group 2) a “good” post-surgery hemodynamic response. Assessments of the 6-min walking distance test (6-min walking distance test [6 MWT]: primary outcome) were performed before and after surgery (before training), after training and at 3-month follow-up. Hemodynamic and lung function data were also analyzed. Results: Data of 84 and 26 patients of groups 1 and 2, respectively, were analyzed. After surgery patients showed a reduction in 6 MWT, which significantly reversed after training and further improved at 3 months (p = 0.0001), without any significant difference between groups. The percentage of patients reaching the minimal clinically important difference in 6 MWT was similar between groups. The significant (p = 0.0001) post-surgery improvement in hemodynamics was maintained at 3 months without any significant difference between groups. New York Heart Association functional class improved in parallel to the hemodynamic improvement. Conclusions: Exercise training in patients with CTEPH after PEA, an inpatient exercise training program, improves exercise capacity for up to 3 months, independently of the post-surgery hemodynamic response.

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“…They experienced improved symptoms as well as improved functional class and quality of life postoperatively without in-hospital mortality, although at a cost of major complications such as reintervention, pneumothorax requiring chest drain insertion, small subdural hematomas, re-intubation and tracheostomy in 40% of patients. Another study confirmed that PEA can reduce exertional dyspnea and improve exercise tolerance in patients with CTED [94]. Although early surgical pulmonary endarterectomy can also be performed to prevent the development of secondary microvasculopathy and progression to CTEPH, the natural history of the disease is unknown and there is no evidence that CTED evolves into CTEPH.…”

Section: Ctedmentioning

confidence: 96%

“…The exercise limitation has been attributed either to exercise-induced pulmonary hypertension or to deadspace ventilation. An abnormal pulmonary vascular reserve, illustrated by an increased slope of the pressureflow relationship [94] and decreased ventilatory efficiency, with increased ventilatory equivalents for carbon dioxide (VE/VCO2), has been reported in CTED patients [19,94]. A reduced RV contractile reserve is associated with the abnormal pulmonary vascular reserve [95].…”

Section: Ctedmentioning

confidence: 99%

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Chronic thromboembolic pulmonary hypertension from the perspective of patients with pulmonary embolism

Klok

Delcroix

Bogaard

2018

Journal of Thrombosis and Haemostasis

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Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but feared long-term complication of acute pulmonary embolism (PE), although CTEPH may occur in patients with no history of symptomatic venous thromboembolism. It represents the most severe presentation of the so-called 'post-PE syndrome', a phenomenon of permanent functional limitations after PE caused by deconditioning after PE or ventilatory or circulatory impairment as a result of unresolved pulmonary artery thrombi. Because the post-PE syndrome may occur in up to 50% of PE survivors, and CTEPH tends to have an insidious and non-specific clinical presentation, CTEPH is often not diagnosed or diagnosed after a very long delay. Once the diagnosis is confirmed, the treatment of choice is pulmonary endarterectomy which effectively lowers the pulmonary vascular resistance and normalizes resting pulmonary artery pressures, leading to recovery of the right ventricle. When pulmonary endarterectomy is not technically feasible, balloon pulmonary angioplasty may be a potential acceptable alternative. Also, medical treatment may help to improve patient's symptoms and hemodynamics. Current studies are focusing on strategies for earlier CTEPH diagnosis after acute PE, as well as the most optimal treatment of inoperable patients. This review will focus on the epidemiology, risk factors, diagnosis and treatment of CTEPH from the perspective of the PE patient.

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Hemodynamic and ventilatory responses during exercise in chronic thromboembolic disease

Abstract: Patients with CTED showed an abnormal pulmonary vascular response to exercise and a decreased ventilatory efficiency. Responses after PEA point to restoration of right ventricle stroke volume response and ventilatory efficiency.

Cited by 76 publications

References 34 publications

Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study

Serial imaging after pulmonary embolism and correlation with functional limitation at 12 months: Results of the ELOPE Study

Exercise Training After Pulmonary Endarterectomy for Patients with Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension from the perspective of patients with pulmonary embolism

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