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Consult

Clinician-to-Clinician Update
To schedule a consultation, referral or appointment in Minneapolis:
Burnsville and Edina:
Maplewood and St. Paul:

To find our pulmonary hypertension care locations, go here.

M Health Fairview Heart Clinic - Minneapolis
M Health Fairview Clinics and Surgery Center - Minneapolis
909 Fulton St. SE, Suite 318
Minneapolis, MN 55455 

M Health Fairview Heart Clinic - Edina
M Health Fairview Southdale Hospital
6405 France Ave. S., Suite W200
Edina, MN 55435 

M Health Fairview Heart Clinic – Burnsville
M Health Fairview Clinics and Specialty Center - Burnsville
14101 Fairview Dr., Suite 140
Burnsville, MN 55337 

M Health Fairview Heart Clinic – Maplewood
1600 Medical Building
1600 St. John's Blvd., Suite 200
Maplewood, MN 55109 

M Health Fairview Heart Clinic – St. Paul
M Health Fairview St. Joseph’s Hospital
45 W. 10th Street
Saint Paul, MN 55102

Innovations in Treating Chronic Thromboembolic Pulmonary Hypertension

The outlook has improved for people with chronic thromboembolic pulmonary hypertension (CTEPH), a subtype of pulmonary hypertension. With the emergence of new procedures often in combination with medical therapies, symptoms of CTEPH can often be resolved. 

Occurring in 3.8% of people with a pulmonary embolism1, CTEPH results from pulmonary emboli that don’t dissolve in the lungs but develop into fibrous tissue that remains in pulmonary arteries. Narrowed arteries cause increased pulmonary vascular resistance, which if unaddressed, leads to right heart failure and death. 

Lungs

Symptoms of CTEPH include shortness of breath and/or chest pain during exertion, fatigue, edema, and syncope in severe cases. Symptoms can be absent in early CTEPH, and the condition can arise in patients without a history of symptomatic pulmonary embolism. Signs of right heart failure appear in advanced stages. Patients with prior history of pulmonary embolism presenting with these symptoms should be evaluated for the possibility of CTEPH. Patients with inherited thrombophilia, antiphospholipid antibody syndrome, chronic indwelling vascular catheters, or splenectomy are more prone to develop CTEPH. 

Assessment for the condition includes a lung ventilation/perfusion scan and angiogram of arterial pulmonary circulation. Confirmatory data include an invasively measured mean pulmonary arterial pressure equal to or greater than 20 mmHg and pulmonary capillary wedge pressure lower than 15 mmHG2, along with mismatched perfusion defects on the ventilation/perfusion scan. Echocardiogram is usually done to evaluate for right-heart enlargement and proper functioning. 

Pulmonary endarterectomy, by removing the clot and normalizing pressure in the arteries, is considered curative and the treatment of choice.3 Nearly half of patients, however, are ineligible for the procedure because of the obstructions’ location in distal vascular branches or segments that are surgically inaccessible, older age, or comorbidities. For these patients with unfavorable surgical risk-to-benefit ratio, alternative interventions are gaining favor and appear to provide comparable improvement in symptoms. 

Balloon pulmonary angioplasty (BPA) holds promise for these patients. In this procedure, a catheter-inserted balloon pushes clots to the side of a clogged artery, making it possible for the body to absorb them. On average, each patient requires 6-7 sessions to reduce pulmonary arterial pressure. According to recent research findings, there is significant improvement in hemodynamics and exercise with BPA,4,5 and reviews of both procedures show similar outcomes.6 

Patients ineligible for pulmonary endarterectomy or who experience persistent or recurrent pulmonary hypertension postprocedure typically are offered BPA. It is often paired with riociguat, the only FDA-approved medication for treating CTEPH. The medication has been shown to improve exercise capacity and hemodynamics.4 Used in Europe for many years, BPA is becoming more common in the United States, especially for patients with technically inoperable disease or unfavorable risk-to-benefit ratio for surgery.7 

The Pulmonary Hypertension Association has certified the M Health Fairview program as a Pulmonary Hypertension Comprehensive Care Center, one of 55 accredited centers of comprehensive care nationally. Such centers demonstrate the highest level of care in the diagnosis and management of all classes of pulmonary hypertension as well as participation in research. Providing comprehensive care to people with pulmonary hypertension, M Health Fairview specialists offer balloon pulmonary angioplasty for CTEPH and are planning to provide pulmonary endarterectomy surgery in 2020.  

References 

  1. McNeil K, Dunning J. Chronic thromboembolic pulmonary hypertension (CTEPH). Heart. 2007 Sep; 93(9):1152-1158. doi: 10.1136/hrt.2004.053603. 
  2. Pepke-Zaba J, Ghofrani H-A, Hoeper M M. Medical management of chronic thromboembolic pulmonary hypertension. Eur Respir Rev. 2017; 26: 160107. doi: 10.1183/16000617.0107-2016 
  3. Sadushi-Kolici R, Lang IM. Medical therapy for CTEPH: is there still space for more? American College of Cardiology website. 2019 Apr 29. https://www.acc.org/latest-in-cardiology/articles/2019/04/29/07/42/medical-therapy-for-cteph Accessed September 2019. 
  4. Lang I, Meyer BC, Ogo T, et al. Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension. Eur Respir Rev. 2017 26: 160119. doi: 10.1183/16000617.0119-2016 
  5. Brenot P, Jaïs X, Taniguchi Y, et al. French experience of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Euro Resp Rev. 2019 May 18;53(5). pii: 1802095. doi:10.1183/13993003.02095-2018. 
  6. Lang IM, Madani M. Update on Chronic Thromboembolic Pulmonary Hypertension. AHA Journals. www.ahajournals.org/doi/pdf/10.1161/CIRCULATIONAHA.114.009309. doi: 10.1161/CIRCULATIONAHA.114.009309. 
  7. Aggarwal V. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. Latest in Cardiology. American College of Cardiology website. 2019 Jul 19. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2019/07/19/10/05/balloon-pulmonary-angioplastypercutaneous Accessed September 2019.

When to refer

M Health Fairview Heart Care cardiologists offer coordinated services focused solely on patients with pulmonary hypertension. Our pulmonary hypertension specialists are skilled in the diagnosis and treatment of the condition and its several subtypes. The specialist team works alongside primary care providers and other specialists in assisting patients and is dedicated to facilitating the optimal introduction of multi-drug therapy, rehabilitation, interventions, or mechanical devices for the long-term management of these diseases. 

A provider dedicated to pulmonary vascular disease services is available to physicians and patients by phone. To speak to the nurse care coordinator, call 612-625-2191. 

Our cardiologists are experienced in the use of the latest combination therapies for the treatment of pulmonary hypertension and can offer balloon pulmonary angioplasty as appropriate for patients with chronic thromboembolic pulmonary hypertension. Patients may also be eligible to participate in one of several clinical trials evaluating treatments for the condition. The M Health Fairview program is a designated Pulmonary Hypertension Comprehensive Care Center

Multidisciplinary, Collaborative Care

Pulmonary hypertension is a complex syndrome that often co-occurs with other health conditions, including heart, lung, or liver disease or connective tissue disorders. Our clinical teams may include cardiologists and interventional cardiologists, cardiac surgeons, transplant surgeons, rheumatologists, pulmonologists, hepatologists, and cardiac nurses to cover all aspects of patient care. Our goals are to relieve each patient’s symptoms and improve quality of life by providing multidisciplinary, collaborative care in close partnership with the referring provider. In cases where organ transplant may be necessary, cardiologists refer their patients to transplant surgeons for evaluation. The M Health Fairview lung transplant program is one of the largest in the nation, with years of experience in setting the standard for transplant care, including performing the first lung transplant in the state of Minnesota.

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