OBJECTIVE:The survival benefit of thrombolysis compared with surgical pulmonary embolectomy for high-risk pulmonary embolism has not been established, although current guidelines advocate thrombolysis as first-line therapy. This study compared the short-term outcomes of surgical pulmonary embolectomy and thrombolysis to determine the optimal treatment for high-risk pulmonary embolism. METHODS:Patients with high-risk pulmonary embolism who underwent surgical pulmonary embolectomy or thrombolysis within 2 days of admission were identified using a nationwide inpatient administrative database in Japan between July 2010 and March 2023. The primary outcome was in-hospital mortality, and secondary outcomes were complications, length of hospital stay, and total hospitalization costs. Outcomes were compared using overlap weighting, with sensitivity analyses conducted using inverse probability of treatment weighting and multivariate logistic regression model. RESULTS:Of the 2813 eligible patients, 526 underwent surgical pulmonary embolectomy, and 2287 underwent thrombolysis. After overlap weighting, surgical pulmonary embolectomy was associated with lower in-hospital mortality (22.2% vs 30.1%, P = .002), more favorable neurological outcomes at discharge (72.5% vs 66.7%, P = .040), and higher total costs ($30,548 vs $13,374, P < .001) than thrombolysis. No significant differences were observed in complications or length of hospital stay between the 2 groups. Sensitivity analyses yielded results consistent with the primary analyses. CONCLUSIONS:These findings suggest potential benefits of surgical pulmonary embolectomy over thrombolysis for high-risk pulmonary embolism. Surgical pulmonary embolectomy may be considered a reasonable reperfusion therapy option for suitable patients. Further research is needed to confirm these findings.

BACKGROUND:Over the past decade, balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension has shown improved outcomes with procedural refinement in expert hospitals with high procedural volume. Whether the outcomes of BPA are reproducible in hospitals with limited procedural volumes remains unknown. The Japan BPA registry was designed to assess the outcomes of contemporary BPA from a nationwide perspective, including hospitals with low treatment volume. METHODS:This prospective multicenter registry enrolled 1202 consecutive patients with chronic thromboembolic pulmonary hypertension who underwent BPA at 44 hospitals between April 2018 and March 2023. We assessed the efficacy and safety of BPA and survival rates, comparing high- and low-volume hospitals based on the BPA center definition (≥50 procedures per year) from the seventh World Symposium on Pulmonary Hypertension. RESULTS:A total of 5207 procedures were performed. Thirty-five low-volume hospitals (79.5%) performed 40.8% of all BPA procedures. BPA significantly improved symptoms, clinical parameters, and hemodynamics (55.6% reduction in pulmonary vascular resistance), with 0.2% periprocedural BPA-related mortality. Severe lung injury (0.3%), balloon overdilatation (0.67%), and mechanical ventilation (0.3%) were less common in high-volume hospitals than in low-volume hospitals (1.3%, 1.7%, and 1.5%, respectively; P<0.001). In the Kaplan-Meier analysis, the survival rate of all patients at 3 years was 94.7% (95% CI, 92.5%-96.3%). Multivariable Cox regression analysis showed an increased mortality risk with higher right atrial pressure, and high-volume hospitals were associated with a reduced mortality risk. CONCLUSIONS:This nationwide registry demonstrated the outcomes of contemporary BPA in patients with chronic thromboembolic pulmonary hypertension. No significant differences were observed in efficacy and periprocedural mortality between low- and high-volume hospitals. However, the significantly lower rate of severe complications in high-volume hospitals indicates that BPA may be safer in high-volume hospitals.

Background Using echocardiography to assess right ventricular (RV) function after cardioplegic arrest is challenging. Cardiac magnetic resonance (CMR) imaging is a superior alternative, with the feature tracking technique enabling quantitative assessment of myocardial deformation. Methods This single-centre, prospective study from 2020 to 2022 assessed RV function in 42 patients who underwent open heart surgery with cardioplegic arrest. CMR data were collected preoperatively, one week postoperatively, and at follow-up (6-12 months after surgery), and assessed using the CMR feature tracking technique. Results Postoperatively, there was no significant fi cant change in RV end-diastolic volume, but RV end-systolic volume significantly fi cantly decreased, leading to a notable increase in RV ejection fraction. By follow-up, both RV end-diastolic and end-systolic volumes had significantly fi cantly reduced compared with the preoperative values. Right ventricular longitudinal contractility decreased after surgery but recovered to the preoperative values by follow-up, while RV circumferential contractility improved postoperatively and remained superior to the preoperative levels at follow-up. Conclusion On CMR imaging, significant fi cant changes in RV systolic motion were observed after cardioplegic arrest, with decreased longitudinal but increased circumferential contractility. At follow up, these changes had reverted to the preoperative patterns by the mid-term (6212 2 12 months).

Abstract The percentage cross‐sectional area of the lung under five (%CSA<5) is the percentage of pulmonary vessels with <5 mm2 area relative to the total lung area on computed tomography (CT). The extent that %CSA<5 is related to pulmonary hemodynamics in patients with chronic thromboembolic pulmonary hypertension (CTEPH) is unclear, as is the effect of pulmonary endarterectomy (PEA) on %CSA<5. Therefore, we aimed to evaluate the clinical significance of %CSA<5 in patients with CTEPH. We studied 98 patients (64 females, mean age 62.5 ± 11.9 years), who underwent CT with %CSA<5 measurement and right heart catheterization (RHC). Patients were classified into groups based on eligibility for PEA. We compared the %CSA<5 with pulmonary hemodynamics measured by RHC in various groups. In 38 patients who underwent PEA, the relationship between %CSA<5 and pulmonary hemodynamics was also evaluated before and after PEA. Significant correlations between %CSA<5 and pulmonary vascular resistance, and compliance, and pulmonary artery pulse pressure were observed in all patients. Pulmonary hemodynamics in the patients who underwent or were eligible for PEA showed a significant correlation with %CSA<5. Additionally, %CSA<5 was significantly lower in the postoperative than in the preoperative group. There was no correlation between changes in %CSA<5 and pulmonary hemodynamics before and after PEA. Furthermore, %CSA<5 did not correlate significantly with prognosis. %CSA<5 may reflect pulmonary hemodynamics in CTEPH with central thrombosis. Furthermore, %CSA<5 was reduced by PEA postoperatively. However, %CSA<5 is not a prognostic indicator, its clinical usefulness in CTEPH patients is limited, and further validation is required.

Abstract Residual pulmonary hypertension (PH) negatively impacts long‐term results following pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We sought to reveal whether modern PH therapy with PH‐targeted medicine and balloon pulmonary angioplasty (BPA) improved long‐term results of residual PH after PEA. Long‐term findings of 80 patients who survived PEA between 2011 and 2019 were retrospectively investigated. One month after PEA, 30 patients developed residual PH defined as mean pulmonary artery pressure (mPAP) ≥25 mmHg, of whom 23 were treated by PH‐targeted medicine and 9 by BPA. Patients with residual PH acquired considerably better functional status and exercise capacity after PEA, however, exhibited significantly worse survival rates than those without. Eleven patients died during follow‐up: 8 patients with residual PH and 3 controls. Among patients with residual PH, the deceased had a significantly lower %decrease in mPAP from 1 month to 1 year following PEA (7.4 [−32.6 to 8.0] % vs. 10.4 [3.7−27.8] %, p = 0.03) and higher mPAP at 1 year following PEA (39.5 [33.25−42.5] vs. 27 [26−34] mmHg, p < 0.01) despite PH‐targeted medicine than the survived. No patients passed away from right heart failure, and there was no difference between the groups in CTEPH‐related mortality. Modern PH therapy was used to address the majority of residual PH. Long‐term survival after PEA was negatively impacted by residual PH, but it appeared that long‐term mortality was also correlated with unrelieved residual PH despite PH‐targeted medicine. Modern PH therapy may have enhanced functional status and excercise capacity, and averted fatal right heart failure.

Background The prognostic value of mixed venous oxygen tension (PvO 2 ) at pulmonary hypertension diagnosis treated with selective pulmonary vasodilators remains unclear. This study sought to investigate the association of PvO 2 with long-term prognosis in pulmonary arterial hypertension (PAH) and medically treated chronic thromboembolic pulmonary hypertension (CTEPH) and to identify the distinct mechanisms influencing tissue hypoxia in patients with CTEPH or PAH. Methods We retrospectively analyzed data from 138 (age: 50.2 ± 16.6 years, 81.9% women) and 268 (age: 57.4 ± 13.1 years, 72.8% women) patients with PAH and CTEPH, respectively, diagnosed at our institution from 1983 to 2018. We analyzed the survival rates of patients with/without tissue hypoxia (PvO 2 < 35 mmHg) and identified their prognostic factors based on the pulmonary hypertension risk stratification guidelines. Results Survival was significantly poorer in patients with tissue hypoxia than in those without it for PAH ( P = 0.001) and CTEPH ( P = 0.017) treated with selective pulmonary vasodilators. In patients with PAH, PvO 2 more strongly correlated with prognosis than other hemodynamic prognostic factors regardless of selective pulmonary vasodilators usage. PvO 2 was the only significant prognostic factor in patients with CTEPH treated with pulmonary hypertension medication. Patients with CTEPH experiencing tissue hypoxia exhibited significantly poorer survival than those in the intervention group ( P < 0.001). PvO 2 more strongly correlated with the cardiac index (CI) than the alveolar-arterial oxygen gradient (A-aDO 2 ) in PAH; whereas in CTEPH, PvO 2 was more strongly correlated with A-aDO 2 than with CI. Conclusions PvO 2 may represent a crucial prognostic factor for pulmonary hypertension. The prognostic impact of tissue hypoxia affects different aspects of PAH and CTEPH, thereby reflecting their distinct pathogenesis.

A 67-year-old male patient required surgical management of an abdominal aortic aneurysm. Contrast-enhanced computed tomography showed a saccular infrarenal abdominal aortic aneurysm and occlusion of the origins of the celiac artery, superior mesenteric artery, and inferior mesenteric artery. Aortography revealed large amounts of blood flow from capillaries around the abdominal aorta to the inferior mesenteric artery and retrograde blood flow to a meandering mesenteric artery through the superior rectal artery. Considering the risk of bowel ischemia, we performed endovascular aneurysm repair with mesenteric artery bypass. The operation was successful, and his postoperative course was uneventful. This procedure could be useful and less invasive.

Rationale and Objectives: Pulmonary endarterectomy (PEA) is one of the most effective treatments for chronic thromboembolic pulmo-nary hypertension (CTEPH). Right heart catheterization (RHC) is the gold standard assessment for pulmonary circulatory dynamics. How-ever, computed tomography (CT) is less invasive than RHC and can elucidate some of the morphological changes caused by thromboembolism. We hypothesized that CT could facilitate the evaluation of heterogeneous pulmonary perfusion. This study investi-gated whether CT imaging features reflect the disease severity and changes in pulmonary circulatory dynamics in patients with CTEPH before and after PEA.Materials and Methods: This retrospective study included 58 patients with CTEPH who underwent PEA. Pre-PEA and post-PEA CT images were assessed for heterogeneity using CT texture analysis (CTTA). The CT parameters were compared with the results of the RHC and other clinical indices and analyzed with receiver operating characteristic curves analysis for patients with and without residual pulmo-nary hypertension (PH) (post-PEA mean pulmonary artery pressure > 25 mmHg).Results: CT measurements reflecting heterogeneity were significantly correlated with mean pulmonary artery pressure. Kurtosis, skew-ness, and uniformity were significantly lower, and entropy was significantly higher in patients with residual PH than patients without resid-ual PH. Area under the curve values of pre-PEA and post-PEA entropy between patients with and without residual PH were 0.71 (95% confidence interval 0.57-0.84) and 0.75 (0.63-0.88), respectively.Conclusion: Heterogeneity of lung density might reflect pulmonary circulatory dynamics, and CTTA for heterogeneity could be a less inva-sive technique for evaluation of changes in pulmonary circulatory dynamics in patients with CTEPH undergoing PEA.

Neurologic adverse events (NAEs) are a major complication after pulmonary endarterectomy (PEA) performed under periods of deep hypothermic circulatory arrest (HCA) for chronic thromboembolic pulmonary hypertension. We modified the PEA strategy to prevent NAEs and evaluated the effectiveness of these modifications. We reviewed the surgical outcomes of 87 patients divided into the following three groups based on the surgical strategy used: group S (n = 49), periods of deep HCA with alpha-stat strategy; group M1 (n = 19), deep HCA with modifications of slower cooling and rewarming rates and the pH–stat strategy for cooling: and group M2 (n = 13), multiple short periods of moderate HCA. PEA provided significant improvement of pulmonary hemodynamics in each group. Sixteen (29

A 64-year-old woman presented to our hospital with fever and dyspnea. She was diagnosed with acute heart failure due to severe mitral regurgitation. However, transesophageal echocardiography revealed large masses on the aortic valve (Figure 1) and the ventricular septum (Figure 2). Vegetation was strongly suspected considering their form, although her blood culture was negative. Therefore, we resected the aortic and mitral valves and the mass on the ventricular septum and performed double valve replacement with the bioprosthesis valves (21 mm Inspiris Resilia in the aortic position and 27 mm Mitris Resilia in the mitral position, Edwards Lifesciences, Irvine, CA). However, their microbiological and histopathological examinations confirmed the patient was not infective endocarditis, and the removed masses (Figure 3) were not vegetation but Lambl’s excrescence. Declaration of conflicting interests

Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension caused by persistent thromboembolism of the pulmonary arteries. In clinical practice, CTEPH patients often show obstructive ventilatory impairment, even in the absence of a smoking history. Recent reports imply a tendency for CTEPH patients to have a lower FEV1.0; however, the mechanism underlying obstructive impairment remains unknown. Methods We retrospectively analyzed CTEPH patients who underwent a pulmonary function test and respiratory impedance test to evaluate their exertional dyspnea during admission for right heart catheterization from January 2000 to December 2019. We excluded patients with a smoking history to rule out the effect of smoking on obstructive impairment. Results A total of 135 CTEPH patients were analyzed. The median FEV1.0/FVC was 76.0%, %FEV (1.0) had a negative correlation with the mean pulmonary artery pressure and pulmonary vascular resistance and the CT Angiogram (CTA) obstruction score. A multivariate regression analysis revealed that the CTA obstruction score was an independent factor of a lower %FEV1.0. In the 54 patients who underwent pulmonary endarterectomy, %FEV1.0 was improved in some cases and was not in some. Mean PAP largely decreased after PEA in the better %FEV1.0 improved cases, suggesting that vascular involvement in CTEPH could be associated with spirometry obstructive impairment. Conclusion %FEV1.0 had a significant correlation with the CTA obstruction score. Obstructive impairment might have an etiological relationship with vascular involvement. Further investigations could shed new light on the etiology of CTEPH.

Left ventricular thrombus is life-threatening when it causes systemic embolization. In cases with a high risk of systemic embolization, left ventricular thrombectomy is recommended. However, the optimal surgical approach is unclear, especially for non-ischemic cardiomyopathy, because left ventriculotomy carries the risk of postoperative cardiac dysfunction. We herein report a male patient with multiple left ventricular thrombi due to acute myocarditis. Endoscopy-assisted left ventricular thrombectomy through right mini-thoracotomy was successfully performed. This method might be an efficient and less-invasive left ventricular thrombectomy for non-ischemic cardiomyopathy.

Preoperative sCD40L of CTEPH patients could be a promising biomarker related to surgical outcome of PEA.

The treatment of acute pulmonary thromboembolism with a hemorrhagic condition is quite challenging and it usually presents a clinical dilemma. Pulmonary embolectomy is generally performed with cardiopulmonary bypass; however, cardiopulmonary bypass usually requires full anticoagulation which cannot be used for patients with a hemorrhagic condition. We herein report a successful case of pulmonary embolectomy that was accomplished using central veno-arterial extracorporeal membranous oxygenation, instead of cardiopulmonary bypass, for a patient with an acute fatal pulmonary thromboembolism and hemorrhagic cerebral infarction following lung cancer surgery. Our strategy consists of surgical embolectomy under central veno-arterial extracorporeal membranous oxygenation with partial anticoagulation and the placement of an inferior vena cava filter to prevent recurrence without the use of anticoagulation therapy.

Pulmonary embolectomy is an effective treatment of acute pulmonary embolism (APE) but not for chronic pulmonary thromboembolism. We described surgical experience of two patients with APE in preexistent unidentified chronic pulmonary thromboembolism. One patient who presented with severe hypoxia but stable hemodynamics underwent successful pulmonary endarterectomy for proximal organized thrombus instead of pulmonary embolectomy. The other patient who required extracorporeal membrane oxygenation for severe hypoxia developed right heart failure because of residual distal organized thrombus after pulmonary embolectomy. Clinical and radiographical presentation of APE in chronic pulmonary thromboembolism mimics APE, and thus, candidates of pulmonary embolectomy should be carefully selected.

This study investigated whether dilated bronchial arteries are associated with reperfusion pulmonary edema in patients with chronic thromboembolic pulmonary hypertension. Results showed that the extent of enlarged bronchial arteries was not associated with the development of reperfusion pulmonary edema, whereas the residual pulmonary hypertension had a significant association.

We report the case of a 72-year-old man with pulmonary valve infective endocarditis, who complained of general malaise for 10 days. He was afebrile but there was no murmur. However, computed tomography showed a large mobile mass attached to the pulmonary valve, and echocardiography showed the same mass attached to the pulmonary valve but not to other valves. We needed to distinguish between vegetation, thrombus, and tumor. After a positive blood culture result, antibiotic treatment was started, but the mass increased in size since the time of hospitalization. We decided to remove the mass. Resection of the vegetation and pulmonary valve replacement were performed 11 days after hospitalization. After antibiotic treatment, the patient was discharged on postoperative day 30. This is a rare case in which infective endocarditis presented only at the pulmonary valve.