Chest
Volume 141, Issue 4, April 2012, Pages 929-934
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Original Research
Pulmonary Vascular Disease
Subpleural Perfusion as a Predictor for a Poor Surgical Outcome in Chronic Thromboembolic Pulmonary Hypertension

https://doi.org/10.1378/chest.11-0769Get rights and content

Background

Small vessel disease is a major determinant of poor outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH). Out-of-proportion pulmonary vascular resistance (PVR) may indicate the presence of small vessel disease, but it is a very subjective evaluation. We investigated poor subpleural perfusion as a marker for small vessel disease and assessed its association with disease severity and surgical outcome of CTEPH.

Methods

We assessed the subpleural perfused area in the capillary phase of pulmonary angiography in 104 consecutive patients, including 45 who underwent surgery, and then divided the patients into either the well-perfused group (the subpleural space in at least one segment was well perfused [n = 75]) or the poorly perfused group (subpleural spaces were either unperfused or minimally perfused in all segments [n = 29]). We compared the pulmonary hemodynamics, degree of distal thrombi, and surgical outcome between these two groups.

Results

The poorly perfused group had significantly higher PVR (937 ± 350 dyne/s/cm5 vs 754 ± 373 dyne/s/cm5, P = .02) and more distal thrombi, resulting in fewer surgically treated patients (27.6% vs 49.3%, P = .04) compared with the well-perfused group. This group showed a higher surgical mortality (62.5% vs 2.7%) and higher postoperative PVR (656 ± 668 dyne/s/cm5 vs 319 ± 223 dyne/s/cm5, P = .04). Even in a multivariate analysis, poor subpleural perfusion was associated with surgical mortality.

Conclusions

Poor subpleural perfusion in the capillary phase of pulmonary angiography might be related to small vessel disease and a poor surgical outcome of CTEPH.

Section snippets

Design and Subjects

This was a retrospective single-center cohort study involving consecutive patients. Between July 2000 and December 2009, 110 patients were diagnosed with CTEPH at Chiba University Hospital. CTEPH was defined as mean PAP ≥ 25 mm Hg with a normal wedge pressure in patients who had dyspnea on exertion for > 6 months. Additionally, lung perfusion scans were required to demonstrate segmental or larger defects concomitant with a normal ventilation scan. Helical CT scan angiography also was performed

Results

Seventy-five patients comprised the well-perfused group, and 29 patients comprised the poorly perfused group. The poorly perfused group had a significantly higher mean PAP (49.5 ± 10.5 mm Hg vs 42.7 ± 11.9 mm Hg, P = .008) and PVR (969 ± 428 dyne/s/cm5 vs 754 ± 367 dyne/s/cm5, P = .013) and a lower central disease score compared with the well-perfused group, resulting in fewer patients meeting the operative criteria (27.6% vs 49.3%, P = .04) (Table 1). The overall hospital mortality after

Discussion

Poor subpleural perfusion was found to be associated with surgical mortality as well as with a higher postoperative PVR. Even in a multivariate analysis, poor subpleural perfusion was associated with poor surgical outcome, although the poorly perfused group showed significantly more severe disease and more distal thrombi compared with the well-perfused group at baseline. To our knowledge, this report is the first to show poor subpleural perfusion to be associated with poor surgical outcome of

Acknowledgments

Author contributions: Dr Tanabe had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Tanabe: contributed to the design of the study, data analysis and interpretation, and writing and review of the entire manuscript.

Dr Sugiura: contributed to the data analysis and critical review of the manuscript.

Dr Jujo: contributed to the data analysis and critical review of the manuscript.

Dr Sakao: contributed to the

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Funding/Support: The present study was supported in part by a grant to the Respiratory Failure Research Group from the Ministry of Health, Labor and Welfare of Japan [No. 23162501 to Dr Tatsumi] and a research grant from the Ministry of Education, Culture, Sports, Science and Technology of Japan [No. 22590849 to Dr Tanabe].

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