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(Circulation. 2009;119:298-305.)
© 2009 American Heart Association, Inc.

Vascular Medicine

Pulmonary Vascular Reactivity and Prognosis in Patients With Chronic Thromboembolic Pulmonary Hypertension

A Pilot Study

Nika Skoro-Sajer, MD; Niklas Hack, MSc; Roela Sadushi-Koliçi, MD; Diana Bonderman, MD; Johannes Jakowitsch, PhD; Walter Klepetko, MD; Mir Ali Reza Hoda, MD; Meinhard P. Kneussl, MD; Peter Fedullo, MD; Irene M. Lang, MD

From the Department of Internal Medicine II, Division of Cardiology (N.S.-S., R.S.-K., D.B., J.J., I.M.L.), Section of Medical Statistics (N.H.), Department of Cardiothoracic Surgery (W.K., M.A.R.H.), Vienna General Hospital, Medical University of Vienna; Wilhelminenspital der Stadt Wien (M.P.K.), Vienna, Austria; and the Division of Pulmonary and Critical Care Medicine (P.F.), University of California, San Diego, Calif.

Correspondence to Irene Lang, MD, Professor of Vascular Biology, Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria. E-mail irene.lang{at}meduniwien.ac.at

Received May 27, 2008; accepted October 22, 2008.

Background— Surgical pulmonary endarterectomy is the preferred treatment for chronic thromboembolic pulmonary hypertension. Persistent pulmonary hypertension after pulmonary endarterectomy has been recognized as a major determinant of poor outcome. We tested whether acute vasoreactivity identifies chronic thromboembolic pulmonary hypertension patients prone to develop persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and whether the degree of acute vasoreactivity affects survival or freedom from lung transplantation.

Methods and Results— Right-sided heart catheterization at baseline and after inhalation of 40 ppm nitric oxide for 20 minutes was performed in 103 patients (56.3±15.3 years old, 53 women). Reductions in mean pulmonary arterial pressure (mPAP; –8.8±12.6%; P<0.0001) and pulmonary vascular resistance (–16.1±18.1%; P<0.0001) and an increase in mixed venous saturation during inhaled nitric oxide (9.1±11.6%; P<0.0001) were observed. Sixty-two patients underwent pulmonary endarterectomy after a median of 49 days (25th and 75th percentiles: 24 and 123 days). Operated patients were followed up for a median of 70.9 months (25th and 75th percentiles: 14 and 97 months). Change in mPAP during inhaled NO was identified as a predictor of persistent/recurrent pulmonary hypertension after pulmonary endarterectomy. Patients experiencing a reduction in mPAP >10.4% with nitric oxide inhalation had a better postoperative outcome. A significant correlation was found between mPAP and immediate postoperative pulmonary vascular resistance (r=0.5, P<0.0001).

Conclusions— A total of 80 (77.7%) of 103 patients demonstrated acute pulmonary vascular reactivity of some degree. A decrease in mPAP >10.4% under inhaled nitric oxide is a predictor of long-term survival and freedom from lung transplantation in adult patients with chronic thromboembolic pulmonary hypertension who are undergoing pulmonary endarterectomy.

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CLINICAL PERSPECTIVE

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