Is the percutaneous approach the future?
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1 Chronic ThromboEmbolic Pulmonary Hypertension Is the percutaneous approach the future? Dr Hélène Bouvaist Cardiology Department Thorax Center Grenoble -France
2 Mr R, 75 years old Dyspnea NYHA 4 Heart failure, oedema ECG : sinusal rythm, Right BBB Echo: LVEF 60%, RV>LV, tricuspid regurgitation 4/4, PH 80 mmhg, RA area 50cm2. Biomarkers : Troponine I<0.02ug/L, NtproBNP=13393ng/L
3 V/Q scan
4 ESC/ERS Guidelines ESCardio.org
5 CT scan
6 Right Heart Catheterism spap (mmhg) dpap (mmhg) mpap (mmhg) PCWP (mmhg) CI (L/min/m 2 ) PVR (UW) SV02 (%) 1st
7 Pulmonary Angiography
8
9 RMI 1st RV mass (gr) Index de masse ventriculair e RV vol (ml/m 2 ) RVEF (%) LV vol(ml/m 2 ) Pericardium Oui Imagerie A.
10 Treatment High risk surgical CTEPH (age and RV dysfunction) Riociguat Refered for balloon pulmonary angioplasty
11 Evolution after BPA Initial After 5 sessions NYHA IV II 6 MWT (m) NTproBNP (ng/l) DLCO (%)
12 Evolution after BPA
13 PAPm (mmhg) et RAP (UW) IC (L/min/m 2 ) Evolution after BPA PAPm RAP IC Bilan initial 3eme séance 5eme séance Contrôle 18mois 6eme séance PAPm RAP IC 1,88 2 2,8 3 1
14 Evolution after BPA initial After RV mass (gr) LV vol (ml/m 2 ) RV vol (ml/m 2 ) RVEF (%) pericardium High Oui Normal Non Imagerie A.
15 Evolution RV function Imagerie A. Jankowski
16 Pulmonary Endo Arteriectomy Surgery is still the referal treatment for CTEPH! French Reference center for CTEPH Bicetre - CCMLannelongue Dia: X.Jais
17 PEA surgery for CTEPH Pulmonary injuries 10% (50% death ) Hospital Mortality 2,2 to 10% in CTEPH referal center D. Jenkins.
18 Balloon Pulmonary Angioplasty : what for? 40 50% inoperable patients regarding distal lesions or comobidities Surgery mortality > 10% if PVR > 15 UiW, age, comorbidités 25% residual CTEPH after PEA Figure 1a : Time to death from date of diagnosis Kaplan Meier survival estimates All patients enrolled, N = Cumulative Survival p=< (log rank test) 0.00 patients at risk at the end of the time period Months from Diagnosis Operated, N=404 Non operated, N=275 Mayer E, Jenkins D, Lindner J, et al. J Thorac Cardiovasc Surg 2011; 141:
19 2012 RAP -65%
20 CTEPH et angioplastie pulmonaire Typical CTEPH lesions Web OCT Anapath Slit Sugiyama M, Fukuda T, Ogo T et al Jul;32(7): Jpn J Radiol Images Dr. Ueda, Dr. Ogo-Ohta, Department of Pathology,NCVC
21 CTEPH and BPA Favorable lesions for BPA 1 2 3
22 CTEPH and BPA Selective angiography +++ Occlusions can be treated by BPA
23 But be carefull with putching! CTEPH et angioplastie pulmonaire
24 In the Cath Lab Operators: 1 cardiologist+1 radiologist Local anesthesia Femoral vein access VKA maintained: INR 2 to 3 NFH bolus UI A1 A1 A3 A3 A1 A2 A2 Flexor long sheat 70cm, 6French A10, Judkins Right or Multipurpose guiding S1 0,014 hydrophilic Wire Coronary/renal angioplasty Balloon ØS3 1,5 a 8 mm A6 A2 A3 A4 A6 A5 A3 A4 A5 A6 A5 A4 A7 A A7 A7 A8 A8 A9 A8 A10 A10 A9 A9 S2 S2 S1 Each session take 1h30 to 2h 2 8 sessions/patients Hospitalization 48-72h S6 S7 S4 vue externe S5 S4 S7
25 CTEPH an
26
27 PVR diminution is corelated with the number of re-opened arteries Lobar Inferior Pulmonary artery Before BPA Lobar Inferior Pulmonary artery After BPA
28 TIPS and TRICK Pressure wire
29 Grenoble PH center Results 70 patients before M3 Improving NYHA 0/4/34/14 18/28/6/0 6MWT 281+/- 130m 356+/-120m +85m mpap mmhg 45+/-9 24+/-6-40% CI L/min/m2 2,1 2,7 + 28% PVR (uiwood) 10,2 3,1-63%
30 Preliminary results - 52 patients Risks & Complications procédures Minor Hémoptysia 15% Embolization 0 Pulmonary injuries 2/52 Renal dysfunction 0 Death 0/52 Irradiation PDS 220 +/- 100 Gy.cm2
31 BPA risk/ benefit inbalance in published series? T. Ogo. Curr Opin Pulm Med Sep;21(5):425-31
32 ESC/ERS Guidelines ESCardio.org
33 CTEPH treatment options in 2016 PEA surgery + specific PH therapy + Balloon Pulmonary Angioplasty + Rehabilitation ESC/ERS Guidelines ESCardio.org
34 «Comparison of 2 treatment options (Riociguat versus balloon pulmonary Angioplasty) in non-operable Chronic thromboembolic pulmonary hypertension» RACE study 23 center of the french PH Network Multidisciplinary CTEPH Team in Paris Control group - Surgery 160 patients 124 inoperable patients randomization Riociguat 62 pts Angioplasty ParisCCML/Grenoble -62pt End Point: PVR - M6 End Point: PVR - M6 Cross over Angioplasty Riociguat
35 «Take home message» - Don t miss the chance of surgery!
36 メルシー
ΔΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ ΤΗΣ ΧΡΟΝΙΑΣ ΘΡΟΜΒΟΕΜΒΟΛΙΚΗΣ ΥΠΕΡΤΑΣΗΣ (CTEPH)
Aristotle University of Thessaloniki Cardiology Clinic, AHEPA Hospital ΔΙΑΓΝΩΣΗ ΚΑΙ ΘΕΡΑΠΕΙΑ ΤΗΣ ΧΡΟΝΙΑΣ ΘΡΟΜΒΟΕΜΒΟΛΙΚΗΣ ΥΠΕΡΤΑΣΗΣ (CTEPH) Charalampos I. Karvounis, MD Professor of Cardiology Aristotle
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