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Noninvasive follow-up strategy after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

Dieuwertje Ruigrok, M. Louis Handoko, Lilian J. Meijboom, Esther J. Nossent, Anco Boonstra, Natalia J. Braams, Jessie van Wezenbeek, Robert Tepaske, Pieter Roel Tuinman, Leo M.A. Heunks, Anton Vonk Noordegraaf, Frances S. de Man, Petr Symersky, Harm-Jan Bogaard
ERJ Open Research 2022 8: 00564-2021; DOI: 10.1183/23120541.00564-2021
Dieuwertje Ruigrok
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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M. Louis Handoko
2Dept of Cardiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Lilian J. Meijboom
3Dept of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Esther J. Nossent
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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  • ORCID record for Esther J. Nossent
Anco Boonstra
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Natalia J. Braams
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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  • ORCID record for Natalia J. Braams
Jessie van Wezenbeek
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Robert Tepaske
4Dept of Intensive Care Medicine, Amsterdam UMC, Academic Medical Center, Amsterdam, the Netherlands
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Pieter Roel Tuinman
5Dept of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Leo M.A. Heunks
5Dept of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Anton Vonk Noordegraaf
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Frances S. de Man
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Petr Symersky
6Dept of Cardiothoracic Surgery, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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Harm-Jan Bogaard
1Dept of Pulmonary Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands
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  • For correspondence: hj.bogaard@amsterdamumc.nl
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  • FIGURE 1
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    FIGURE 1

    Flow chart of patient selection. CPET: cardiopulmonary exercise testing; ICU: intensive care unit; LTX: lung transplantation; NT-proBNP: N-terminal pro-brain natriuretic peptide; PEA: pulmonary endarterectomy; RHC: right heart catheterisation; TTE: transthoracic echocardiography.

  • FIGURE 2
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    FIGURE 2

    Correlation analysis of mean pulmonary artery pressure (mPAP) between ICU and 6-month re-evaluation after pulmonary endarterectomy (PEA). Spearman correlation performed. ICU: intensive care unit.

  • FIGURE 3
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    FIGURE 3

    mPAP distribution according to TTE PH probability. Mann–Whitney test performed. mPAP: mean pulmonary artery pressure; PH: pulmonary hypertension; TTE: transthoracic echocardiography.

Tables

  • Figures
  • TABLE 1

    Pre-operative characteristics

    Parameters before PEATotal (n=92)Patients without residual PH after PEA (n=56)Patients with residual PH after PEA (n=36)
    Age at PEA (years)63 (range 17–79)58 (range 18–79)63 (range 17–79)
    Women41 (45%)24 (43%)17 (47%)
    BMI (kg·m−2)26.7 (24.3–30.1)26.7 (23.8–30.1)26.5 (25.0–30.0)
    Use of PH-specific medication before PEA27 (29%)13 (23%)14 (39%)
    NYHA class I/II/III/IV (%)2/38/52/84/37/48/110/38/59/3
    6MWD (m)412±108, n=67413±112, n=39411±105, n=28
    NT-proBNP (ng·L−1)507 (132–1646)326 (115–1250)932 (224–2748)
    Comorbidities
     Ischaemic heart disease3 (3%)0 (0%)3 (8%)
     Obstructive lung disease12 (13%)6 (11%)6 (17%)
     Diabetes mellitus8 (9%)5 (9%)3 (8%)
     Systemic hypertension35 (38%)18 (32%)17 (47%)
     Malignancy6 (7%)4 (7%)2 (6%)
     Thyroid disease7 (8%)3 (5%)4 (11%)

    Data are presented as mean±sd, median (interquartile range) or n (%) unless otherwise stated. 6MWD: 6-min walk distance; BMI: body mass index; NT-proBNP: N-terminal pro-brain natriuretic peptide; NYHA: New York Heart Association; PEA: pulmonary endarterectomy; PH: pulmonary hypertension.

    • TABLE 2

      Univariate logistic regression analysis of CPET parameters for residual PH

      ParameterOR95% CIp-value
      Peak load <80% predicted4.0231.434–11.2830.008
      Peak V′O2 <80% predicted5.3861.813–16.0010.002
      V′O2/WR <8.4 mL·min−1·W−113.4174.558–39.491<0.001
      O2 pulse <80% predicted3.1541.260–7.8910.014
      PETCO2 peak exercise <4.0 kPa2.6671.097–6.4840.030
      V′E/V′CO2 AT ≥34.04.7881.866–12.2900.001
      SpO2 peak exercise ≤94%1.9200.771–4.7810.161

      AT: anaerobic threshold; CPET: cardiopulmonary exercise testing; PETCO2: end-tidal carbon dioxide partial pressure; PH: pulmonary hypertension; V′E/V′CO2: ventilatory equivalent for carbon dioxide; V′O2: oxygen consumption; SpO2: peripheral oxygen saturation; WR: work rate.

      • TABLE 3

        Test characteristics of CPET parameters for residual PH

        ParameterSensitivitySpecificityPPVFalse-positive ratePositive LRNPVFalse-negative rateNegative LRNumber-needed-to-catheterise
        Peak load <80% predicted28/34 (0.82)25/54 (0.46)28/57 (0.49)29/57 (0.51)1.5325/31 (0.81)6/31 (0.19)0.3857/88 (0.65)
        Peak V′O2 <80% predicted29/34 (0.85)26/54 (0.48)29/57 (0.51)28/57 (0.49)1.6426/31 (0.84)5/31 (0.16)0.3157/88 (0.65)
        V′O2/WR <8.4 mL·min−1·W−123/31 (0.74)42/51 (0.82)23/32 (0.72)9/32 (0.28)4.2042/50 (0.84)8/50 (0.16)0.3132/82 (0.39)
        O2 pulse <80% predicted17/34 (0.50)41/54 (0.76)17/30 (0.57)13/30 (0.43)2.0841/58 (0.71)17/58 (0.29)0.6630/88 (0.34)
        PETCO2 peak exercise <4.0 kPa22/34 (0.65)32/54 (0.59)22/44 (0.50)22/44 (0.50)1.5932/44 (0.73)12/44 (0.27)0.6044/88 (0.50)
        V′E/V′CO2 AT ≥3422/32 (0.69)37/54 (0.69)22/39 (0.56)17/39 (0.44)2.1837/47 (0.79)10/47 (0.21)0.4639/86 (0.45)

        AT: anaerobic threshold; CPET: cardiopulmonary exercise testing; LR: likelihood ratio; NPV: negative predictive value; PETCO2: end-tidal carbon dioxide partial pressure; PH: pulmonary hypertension; PPV: positive predictive value; V′E/V′CO2: ventilatory equivalent for carbon dioxide; V′O2: oxygen consumption; WR: work rate.

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        Noninvasive follow-up strategy after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension
        Dieuwertje Ruigrok, M. Louis Handoko, Lilian J. Meijboom, Esther J. Nossent, Anco Boonstra, Natalia J. Braams, Jessie van Wezenbeek, Robert Tepaske, Pieter Roel Tuinman, Leo M.A. Heunks, Anton Vonk Noordegraaf, Frances S. de Man, Petr Symersky, Harm-Jan Bogaard
        ERJ Open Research Apr 2022, 8 (2) 00564-2021; DOI: 10.1183/23120541.00564-2021

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        Noninvasive follow-up strategy after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension
        Dieuwertje Ruigrok, M. Louis Handoko, Lilian J. Meijboom, Esther J. Nossent, Anco Boonstra, Natalia J. Braams, Jessie van Wezenbeek, Robert Tepaske, Pieter Roel Tuinman, Leo M.A. Heunks, Anton Vonk Noordegraaf, Frances S. de Man, Petr Symersky, Harm-Jan Bogaard
        ERJ Open Research Apr 2022, 8 (2) 00564-2021; DOI: 10.1183/23120541.00564-2021
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