Carlos Andrés Quezada

Lung and heart-lung transplantation in pulmonary arterial hypertension

Background Real use of lung (LT) and heart-lung (HLT) transplantation in pulmonary arterial hypertension (PAH) is unknown. The objectives were to describe the indication of these procedures on PAH treatment in a national cohort of PAH patients, and to analyze the potential improvement of its indication in severe patients. Methods Eligibility for LT/HLT was assessed for each deceased patient. Incident patients from REHAP diagnosed between January 2007 and March 2015 and considered eligible for LT/HLT were grouped as follows: those who finally underwent transplantation (LTP) and those who died (D-Non-LT). Findings Of 1391 patients included in REHAP, 36 (3%) were LTP and 375 (27%) died. Among those who died, 36 (3%) were D-Non-LT. LTP and D-Non-LT were equal in terms of age, gender, and clinical status. Ten percent of those who died were functional class I-II. Patients functional class IV were less likely to undergo LT (8.3% LTP vs. 30.6% D-Non-LT, p = 0.017). Patients with idiopathic and drug/toxin-associated PAH were more likely to undergo LT (44.4% LTP vs. 16.7% D-Non-LT, p = 0.011). Conclusions The present results show that the use of LT/HLT could double for this indication. Relevant mortality in early functional class reflects the difficulties in establishing the risk of death in PAH.

Diclofenac for reversal of right ventricular dysfunction in acute normotensive pulmonary embolism: A pilot study

BACKGROUNDnThe inflammatory response associated with acute pulmonary embolism (PE) contributes to the development of right ventricular (RV) dysfunction. Nonsteroidal anti-inflammatory drugs (NSAIDs) may facilitate the reversal of PE-associated RV dysfunction.nnnMETHODSnWe randomly assigned normotensive patients who had acute PE associated with echocardiographic RV dysfunction and normal systemic blood pressure to receive intravenous (IV) diclofenac (two doses of 75mg in the first 24h after diagnosis) or IV placebo. All patients received standard anticoagulation with subcutaneous low-molecular-weight heparin (LMWH) and an oral vitamin K antagonist. RV dysfunction was defined by the presence of, at least, two of the following criteria: i) RV diastolic diameter>30mm in the parasternal window; ii) RV diameter>left ventricle diameter in the apical or subcostal space; iii) RV free wall hypokinesis; and iv) estimated pulmonary artery systolic pressure>30mmHg. Persistence of RV dysfunction at 48h and 7days after randomization were the primary and secondary efficacy outcomes, respectively. The primary safety outcome was major bleeding within 7days after randomization.nnnRESULTSnOf the 34 patients randomly assigned to diclofenac or placebo, the intention-to-treat analysis showed persistent RV dysfunction at 48h in 59% (95% confidence interval [CI], 33-82%) of the diclofenac group and in 76% (95% CI, 50-93%) of the placebo group (difference in risk [diclofenac minus standard anticoagulation], -17 percentage points; 95% CI, -47 to 17). Similar proportions (35%) of patients in the diclofenac and placebo groups had persistent RV dysfunction at 7days. Major bleeding occurred in none of patients in the diclofenac group and in 5.9% (95% CI, 0.2-29%) of patient in the placebo group.nnnCONCLUSIONSnDue to slow recruitment, our study is inconclusive as to a potential benefit of diclofenac over placebo to reverse RV dysfunction in normotensive patients with acute PE.nnnCLINICAL TRIAL REGISTRATIONnURL: http://www.clinicaltrials.gov. Unique identifier: NCT01590342.

Assessment of coexisting deep vein thrombosis for risk stratification of acute pulmonary embolism

BACKGROUNDnIn patients with acute pulmonary embolism (PE), studies have shown an association between coexisting deep vein thrombosis (DVT) and short-term prognosis. It is not known whether complete compression ultrasound testing (CCUS) improves the risk stratification of their disease beyond the recommended prognostic models.nnnMETHODSnWe included patients with normotensive acute symptomatic PE and prognosticated them with the European Society of Cardiology (ESC) risk model for PE. Subsequently, we determined the prognostic significance of coexisting DVT in patients with various ESC risk categories. The primary endpoint was a complicated course after the diagnosis of PE, defined as death from any cause, haemodynamic collapse, or adjudicated recurrent PE.nnnRESULTSnAccording to the ESC model, 37% of patients were low-risk, 56% were intermediate-low risk, and 6.7% were intermediate-high risk. CCUS demonstrated coexisting DVT in 375 (44%) patients. Among the 313 patients with low-risk PE, coexisting DVT (46%) did not show a significant increased risk of complicated course (2.8%; 95% confidence interval [CI], 0.8%-7.0%), compared with those without DVT (0.6%; 95% CI, 0%-3.2%), (Pu202f=u202f0.18). Of the 478 patients with intermediate-low risk PE, a complicated course was 14% and 6.8% for those with and without DVT, respectively (Pu202f=u202f0.01). Of the 57 patients that had intermediate-high risk PE, a complicated course occurred in 17% and 18% for those with and without DVT, respectively (Pu202f=u202f1.0).nnnCONCLUSIONSnIn normotensive patients with PE, testing for coexisting DVT might improve risk stratification of patients at intermediate-low risk for short-term complications.

Correction: Lung and heart-lung transplantation in pulmonary arterial hypertension

[This corrects the article DOI: 10.1371/journal.pone.0187811.].

Surrogate Endpoints for Pulmonary Hypertension Management and Trial Design: Moving in the Right Direction

SEE PAGE 752 P ulmonary arterial hypertension (PAH) still has a poor prognosis despite the advances in treatment options that have occurred over the past 2 decades (1). The World Health Organization (WHO) functional (disease severity) classification for PAH strongly predicts mortality (2). A 2015 clinical practice guideline proposed a goal-oriented PAH treatment strategy based on a comprehensive risk stratification that includes assessments of WHO functional class, clinical signs of right heart failure, exercise capacity (e.g., 6-min walking test [6MWT] or cardiopulmonary exercise testing), and right ventricular function (brain natriuretic peptide, N-terminal pro-brain natriuretic peptide, or echocardiography) (3). Using the guideline’s risk definitions, investigators recently used the SPAHR registry (Swedish PAH Registry) to explore the potential prognostic advantage of moving from a non–low-risk profile to a low-risk profile (4). Of the 530 registry patients, 383 completed a 1-year follow-up assessment. The 54 patients who improved from non-low risk to low risk had similar 1-, 3-, and 5-year survival (98%, 96%, and 96%) compared with the 57 patients who remained in the low-risk subgroup at baseline and during follow-up (100%, 98%, and 89%) (4). Because the study also showed that the 59 patients who deteriorated in risk category (i.e., from lowto intermediateor high-risk categories) had worse survival, it provided the

Éxito en la recuperación de filtro de vena cava inferior opcional: Análisis de 246 pacientes

OBJECTIVEnThis study assessed vena cava filter (VCF) retrieval rates and factors associated with retrieval failure in a single center cohort.nnnMETHODSnWe conducted an observational retrospective cohort study. The primary endpoint was the percentage of patients whose VCF was retrieved. We performed logistic regression to identify variables associated with retrieval failure.nnnRESULTSnDuring the study period, 246 patients received a VCF and met the eligibility requirements to be included in the study; 151 (61%) patients received a VCF due to contraindication to anticoagulation, 69 (28%) patients had venous thromboembolism (VTE) and a high risk of recurrence, and 26 (11%) patients received a filter due to recurrent VTE while on anticoagulant therapy. Of 236 patients who survived the first month after diagnosis of VTE, VCF was retrieved in 96%. Retrieval rates were significantly lower for patients with recurrent VTE while on anticoagulation, compared with patients with contraindication to anticoagulation or patients with a high risk of recurrence (79% vs. 97% vs. 100%, respectively; P<0.01). Mean time to retrieval attempt was significantly associated with retrieval failure (137.8xa0±xa065.3 vs. 46.3xa0±xa0123.1 days, P<0.001).nnnCONCLUSIONSnIn this single center study, VCF retrieval success was 96%. A delay in the attempt to retrieve the VCF correlated significantly with retrieval failure.

Accuracy and Interobserver Reliability of the Simplified Pulmonary Embolism Severity Index Versus the Hestia Criteria for Patients With Pulmonary Embolism

OBJECTIVESnThe objective was to assess and compare the accuracy and interobserver reliability of the simplified Pulmonary Embolism Severity Index (sPESI) and the Hestia criteria for predicting short-term mortality in patients with pulmonary embolism (PE).nnnMETHODSnThis prospective cohort study evaluated consecutive eligible adults with PE diagnosed in the emergency department (ED) at a large, tertiary, academic medical center in the era January 1, 2015, to December 30, 2017. We assessed and compared sPESI and Hestia criteria prognostic accuracy for 30-day all-cause mortality after PE diagnosis and their interobserver reliability for classifying patients as low risk or high risk. Two clinician investigators scored both prediction tools during the ED evaluation. We used the kappa statistic to test for agreement.nnnRESULTSnThe 488-patient cohort had a mean (±SD) age of 69.0 (±17.1) years and an approximately even sex distribution. The investigators classified one-quarter of patients as low risk using the sPESI and Hestia criteria (28% vs. 27%, respectively). During the 30-day follow-up, 31 of the 488 (6.4%) patients died. Patients classified as low risk according to the sPESI and the Hestia criteria had a similar 30-day mortality (sPESI 0.7% [1/135], 95% confidence interval [CI] = 0.0%-4.0%; Hestia 2.3% [3/132], 95% CI = 0.5%-6.5%). The two observers had good agreement (κ = 0.80) for the Hestia criteria and very good agreement (κ = 0.97) for the sPESI.nnnCONCLUSIONnThe sPESI and the Hestia criteria had similar risk classification determination and prognostic accuracy for 30-day mortality after PE. However, the succinct and more objective sPESI had higher interobserver reliability than the Hestia criteria.