Pulmonary hemodynamics in advanced COPD candidates for lung volume reduction surgery or lung transplantation

STUDY OBJECTIVES: To assess the pulmonary hemodynamic characteristics in COPD candidates for lung volume reduction surgery (LVRS) or lung transplantation (LT). DESIGN: Retrospective study. SETTING: One center in France. PATIENTS: Two hundred fifteen patients with severe COPD who underwent right-heart catheterization before LVRS or LT. RESULTS: Mean age was 54.6 years. Pulmonary function test results were as follows: FEV(1), 24.3% predicted; total lung capacity, 128.3% predicted; residual volume, 259.7% predicted. Mean pulmonary artery pressure (PAPm) was 26.9 mm Hg. Pulmonary hypertension (PAPm > 25 mm Hg) was present in 50.2% and was moderate (PAPm, 35 to 45 mm Hg) or severe (PAPm > 45 mm Hg) in 9.8% and in 3.7% of patients, respectively. Cardiac index was low normal. PAPm was related to Pao(2) and alveolar-arterial oxygen gradient in multivariate analysis. Cluster analysis identified a subgroup of atypical patients (n = 16, 7.4%) characterized by moderate impairment of the pulmonary mechanics (mean FEV(1), 48.5%) contrasting with high level of pulmonary artery pressure (PAPm, 39.8 mm Hg), and severe hypoxemia (mean Pao(2), 46.2 mm Hg). CONCLUSION: While pulmonary hypertension is observed in half of the COPD patients with advanced disease, moderate-to-severe pulmonary hypertension is not a rare event in these patients. We individualized a subgroup of patients presenting with a predominant vascular disease that could potentially benefit from vasodilators.     

Pulmonary Artery Denervation Attenuates Pulmonary Arterial Remodeling in Dogs With Pulmonary Arterial Hypertension Induced by Dehydrogenized Monocrotaline

ObjectivesThis study aimed to investigate sympathetic nerve (SN) ultrastructural changes and hemodynamic and pulmonary artery (PA) pathological improvements by pulmonary arterial denervation (PADN) in animals with pulmonary arterial hypertension (PAH), as well as the underlying mechanisms.BackgroundSN overactivity plays a role in PAH. Previous studies have reported short-term improvements in pulmonary arterial pressure (PAP) and cardiac function by PADN, but PA remodeling and the associated mechanisms remain unclear.MethodsForty dogs were randomly (ratio of 1:3) assigned to the control (intra-atrial injection of N-dimethylacetamide, 3 mg/kg) and test (intra-atrial injection of dehydrogenized-monocrotaline, 3 mg/kg) groups. After 8 weeks, the animals in the test group with a mean PAP >25 mm Hg (n = 20) were randomized (ratio of 1:1) into the sham and PADN groups. At 14 weeks, the hemodynamics, medial wall thickness and PA muscularization, and messenger ribonucleic acid expression of genes in lung tissues were measured. Another 35 PAH dogs were used to measure the SN conduction velocity, electron microscopic assessment, and nerve distribution.ResultsPADN induced significant SN demyelination and axon loss and slowed SN conduction velocity over time, with resulting profound reductions in the mean PAP (23.5 ± 2.3 mm Hg vs. 33.7 ± 5.8 mm Hg), pulmonary vessel resistance (3.5 ± 2.3 Wood units vs. 7.7 ± 1.7 Wood units), medial wall thickness (22.3 ± 3.3% vs. 30.4 ± 4.1%), and full muscularization (40.3 ± 9.3% vs. 57.1 ± 5.7%) and increased nonmuscularization (29.8 ± 6.1% vs. 12.9 ± 4.9%) compared with the Sham group (all p < 0.001). PADN inhibited the messenger ribonucleic acid expression of genes correlated with inflammation, proliferation, and vasoconstriction.ConclusionsPADN induces permanent SN injury and subsequent improvements in hemodynamics and PA remodeling in animals with PAH through mechanisms that may be experimentally and clinically beneficial.     

Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography

BACKGROUND: Hemoptysis of pulmonary arterial origin is a diagnostic challenge in patients admitted to a respiratory ICU (RICU) for treatment of hemoptysis. Its early accurate recognition and treatment reduce morbidity and prevent mortality. Multidetector row CT angiography (MDCTA) is an accurate method for imaging the systemic vascular network. Our aim was to assess the MDCTA signs and role in managing hemoptysis of pulmonary arterial origin. METHODS: We performed a retrospective clinical and radiologic analysis of all consecutive patients who were referred for severe hemoptysis to our RICU and were treated by endovascular means between January 2004 and December 2006. We reviewed all of those cases with hemoptysis of pulmonary arterial origin. RESULTS: Of 272 patients who were referred for severe hemoptysis to the RICU, 189 patients were treated by endovascular means. Thirteen patients (nine men, four women; mean age, 45 years) had hemoptysis of pulmonary arterial origin. Signs of pulmonary arterial hemoptysis seen on MDCTA were of the following three types: pseudoaneurysm (n = 5); aneurysm of the pulmonary artery (n = 3); or the presence of a pulmonary artery in the inner wall of a cavity (n = 5). Hypertrophy of the bronchial arteries seen on MDCTA associated with any of these signs predicted the necessity to treat both the bronchial and pulmonary arteries. Pulmonary artery vasoocclusion was performed as a first treatment in eight patients with such an association (n = 1) or without such an association (n = 7) along with bronchial artery embolization. The remaining five patients were treated with systemic artery embolization, followed by surgery (n = 1), pulmonary artery vasoocclusion (n = 3), and death from massive hemoptysis (n = 1). CONCLUSIONS: MDCTA performed prior to endovascular treatment allows the correct identification and early appropriate management of severe hemoptysis of pulmonary arterial origin.