EXPRESS: Optimizing CTEPH diagnosis and assessment using advancing imaging modalities

Imaging is key to nearly all aspects of chronic thromboembolic pulmonary hypertension (CTEPH) including management for screening, assessing eligibility for pulmonary endarterectomy, and post-operative follow-up. While ventilation/perfusion (V/Q) scintigraphy, the gold standard technique for CTEPH screening, can have excellent sensitivity, it can be confounded by other etiologies of pulmonary malperfusion, and does not provide structural information to guide operability assessment. Conventional computed tomography pulmonary angiography (CTPA) has high specificity, though findings of CTEPH can be visually subtle and unrecognized. In addition, CTPA can provide morphologic information to aid in pre-operative workup and assessment of other structural abnormalities. Advances in computed tomography (CT) imaging techniques, including dual-energy CT (DECT) and spectral-detector CT allow for improved sensitivity and specificity in detecting CTEPH, comparable to that of V/Q scans. Furthermore, these advanced CT techniques, compared with conventional CT, provide additional physiologic data from perfused blood volume maps and improved resolution to better visualize distal CTEPH, an important consideration for balloon pulmonary angioplasty for inoperable patients. Electrocardiogram (ECG)-synchronized techniques in ECG-gated CT can also show further information regarding right ventricular function and structure. While the standard of care in the workup of CTEPH includes a V/Q scan, CTPA, direct catheter angiography, echocardiogram, and coronary angiogram, in the future a ECG-gated DECT angiography scan may enable a “one-stop” imaging study to guide diagnosis, operability assessment, and treatment decisions with less radiation exposure and cost than traditional CTEPH imaging modalities.

A successful case of heart transplantation concurrent with pulmonary thromboendarterectomy

Introduction: Pre-transplant irreversible pulmonary hypertension and high pulmonary vascular resistance are generally considered as contraindications for orthotopic heart transplantation due to the high risk of right ventricular dysfunction after transplantation. However, there is no consensus on whether reversible pulmonary hypertension increases the incidence of post-transplant complications and mortality. Case report: A patient with acute heart failure and pulmonary artery occlusion successfully underwent heart transplantation concurrent with pulmonary thromboendarterectomy. Discussion and Conclusion: This case illustrates that heart transplantation concurrent with pulmonary thromboendarterectomy can be performed successfully with meticulous operability assessment, superb surgical technique and careful perioperative management.

Feasibility of a Noninvasive Operability Assessment in Chronic Thromboembolic Pulmonary Hypertension under Real-World Practice

This study aimed to evaluate the feasibility of a noninvasive operability assessment of chronic thromboembolic pulmonary hypertension (CTEPH) based on multidetector computed tomographic angiography (MCTA). Up to 176 patients were evaluated from January 2016 to April 2018. Throughout the first phase, the initial surgical decision was made based on MCTA with further analysis of pulmonary angiography (PA) in order to evaluate in which cases the initial decision was not modified by PA. During the second phase, PA was limited to patients judged inoperable based on MCTA or those whose assessment was not possible. Patients deemed operable (50%) based on MCTA along the first phase had been adequately classified, as PA did not modify the initial decision in all but one patient. Comparable results were obtained throughout the implementation phase. Regarding operated patients, the decision of operability was based solely on MCTA in 94% of those with level I disease, in 75% with level II, and 54% with level III. This approach enabled shorter periods of time to complete surgical assessment and the avoidance of PA-related morbidity. Baseline parameters, postoperative measures, and survival rates at 1 year after surgery were comparable in both phases. Noninvasive operability assessment is feasible in a subset of CTEPH patients and optimizes surgical candidacy evaluation.

Feasibility of a noninvasive operability assessment in chronic thromboembolic pulmonary hypertension under real-world practice.

Background – The development of an optimized assessment of operability in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is crucial. This study aimed to evaluate the feasibility of a noninvasive operability assessment of CTEPH based on multidetector computed tomographic angiography (MCTA). Methods –176 patients with CTEPH were evaluated from January 2016 to April 2018. Throughout the first phase, operability was assessed with MCTA and pulmonary angiography (PA): initial surgical decision was made based on MCTA with further analysis of PA to evaluate which cases initial decision was not modified by PA. During the second phase, PA was limited to patients judged inoperable based on MCTA or in those whose assessment was not possible. Results – Patients deemed operable (50%) based on MCTAalong the first phase, had been adequately classified, as PA did not modify the initial decision in all but one patient. Comparable results were obtained throughout the implementation phase, in which decision of operability was based on MCTA in 49% of the patients. Regarding operated patients, decision of operability had been based solely on MCTA in 94% of those with level I disease regarding intraoperative CTEPH classification; in 75% with level II disease and 54% with level III. This approach enabled shorter time periods to complete surgical assessment and the avoidance of PA-related morbidity. Baseline parameters, postoperative measures and survival rates at 1 year after surgerywere comparable in both phases. Conclusions - Noninvasive operability assessment is feasible in a subset of CTEPH patients and optimizessurgical candidacy evaluation.