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Chronic thromboembolic pulmonary hypertension (CTEPH) has a poor prognosis be-cause of increased pulmonary arterial pressure (PAP) causing pulmonary hypertension and progressive right-sided heart failure.1,2 Typical symptoms are dyspnea on exertion, fatigability, and reduced quality of life.
PULMONARY RESEARCH AND RESPIRATORY MEDICINE ISSN 2377-1658 http://dx.doi.org/10.17140/PRRMOJ-4-e007 Open Journal Editorial Balloon Pulmonary Angioplasty (BPA) and * *Corresponding author Rehabilitation for Chronic Thromboembolic Masahiro Kohzuki, MD, PhD Department of Internal Medicine and Pulmonary Hypertension (CTEPH) Rehabilitation Science Tohoku University Graduate School of Medicine 1-1, Seiryo-cho, Aoba-ku * Masahiro Kohzuki, MD, PhD Sendai, Japan Tel. 022-717-7351 Fax: 022-717-7355 Department of Internal Medicine and Rehabilitation Science, Tohoku University Graduate E-mail: kohzuki@med.tohoku.ac.jp School of Medicine, 1-1, Seiryo-cho, Aoba-ku, Sendai, Japan Volume 4 : Issue 2 Article Ref. #: 1000PRRMOJ4e007 Chronic thromboembolic pulmonary hypertension (CTEPH) has a poor prognosis be- cause of increased pulmonary arterial pressure (PAP) causing pulmonary hypertension and 1,2 progressive right-sided heart failure.1,2 Typical symptoms are dyspnea on exertion, fatigability, Article History th and reduced quality of life. Balloon pulmonary angioplasty (BPA) has been reported to im- Received: March 28 , 2017 th prove hemodynamics and functional capacity in patients with CTEPH who are not candidates Accepted: March 28 , 2017 4,5 th for pulmonary endarterectomy. However, the effect of BPA on respiratory function in patients Published: March 28 , 2017 with CTEPH is unclear.
Citation Recently, Akizuki et al3 investigated how BPA affects hemodynamics, ventilatory Kohzuki M. Balloon pulmonary an- efficiency, and gas exchange in patients with CTEPH using right heart catheterization, respira- gioplasty (BPA) and rehabilitation for tory function testing, and cardiopulmonary exercise testing (CPX). They enrolled patients with chronic thromboembolic pulmonary inoperable CTEPH who underwent BPA primarily in lower lobe arteries and upper and middle hypertension (CTEPH). Pulm Res Respir Med Open J. 2017; 4(2): e1- lobe arteries. They compared changes in hemodynamics and respiratory function between dif- e2. doi: 10.17140/PRRMOJ-4-e007 ferent BPA fields.
They showed differences in the effect of BPA on respiratory function in different BPA fields in patients with CTEPH. Mean PAP and pulmonary vascular resistance significantly im- proved. Oxygenation at rest and during exercise improved regardless of the BPA field. However, the time course of changes in the percent predicted diffusion capacity of lung for carbon monoxide (% DLCO), The ventilation/CO2 production (VE/VCO2) slope, and FETCO2 was significantly different between lower and upper/middle lung BPA fields. %DLCO decreased after BPA in the lower lung field with no recovery. However, %DLCO increased after BPA in the upper middle lung field and continued to improve during the follow-up. VE/VCO2 slope significantly improved after BPA in the lower lung field and continued to improve during the follow-up. However, the VE/VCO2 slope remained unchanged after BPA in the upper/middle lung field. Therefore, the effect of BPA on respiratory function in patients with CTEPH differed depend- ing on the lung field.3 Based on their results, they suggested that BPA in the lower lung field improves oxygen- ation and respiratory function parameters during exercise, such as VE/VCO2 slope and FETCO2, because of remarkable improvement in hemodynamics. They also suggested that BPA in the upper/middle lung field may improve oxygenation and respiratory function parameters at rest, such as %DLCO, caused by improvement in V/Q mismatch.3 Copyright However, reduced DLCO in CTEPH reflects not only the effect of low V/Q but also dead ©2017 Kohzuki M. This is an open space ventilation (deadspace/tidal volume [VD/VT]) in regions with high V/Q. Further, one hy- access article distributed under the Creative Commons Attribution 4.0 pothesis suggests that in patients with CTEPH, a decrease in DLCO also indicates microvascular International License (CC BY 4.0), 6 remodeling. Results of previous reports that DLCO remained unchanged even after successful which permits unrestricted use, 7,8 pulmonary endarterectomy and BPA supported the hypothesis.
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Open Journal ISSN 2377-1658 http://dx.doi.org/10.17140/PRRMOJ-4-e007 These points of view suggest that reduced DLCO in patients with CTEPH may be caused by low V/Q, high V/Q and mi- crovascular remodeling.6 Therefore, it is important to distinguish the effects of these three components when discussing DLCO in CTEPH. To obtain further evidence to support their hypothesis, Takei et al6 suggest analyzing the VD/VT and shunt fraction (Qs/Qt) to distinguish the amelioration of high V/Q and deterioration of low V/Q in different lung lobes.6 The goal of effective CTEPH management is to relieve symptoms, slow disease progression, improve exercise tolerance, prevent and treat complications, and improve prognosis and overall quality of life. The clinical presentation of CTEPH is similar to pulmonary arterial hypertension (PAH) with nonspecific symptoms. Further studies are required to elucidate to noninvasively ex- amine the severity of CTEPH and to noninvasively distinguish CTEPH from PAH, for example, by respiratory function or ventilator gas analysis in different postures.