Journal CHEST®
Association Between Thrombus Histopathology and Hemodynamic Outcomes Among Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy
By Louisa A. Mounsey, MD, and colleagues
The histopathology of chronic thromboembolic pulmonary hypertension is complex. Specimen tissue can be classified according to lesion age as subacute (organizing), chronic (organized—characterized by intimal proliferation, fibrosis, and hyperplasia), or mixed. Is there a relationship between specimen pathology and hemodynamic outcomes following pulmonary endarterectomy (PEA)?
Mounsey and colleagues retrospectively analyzed PEA specimens from 157 patients. In this single-center cohort, 34% had organized clots, 17% had organizing thrombi, and the remaining 49% had mixed features. Those with mixed thrombi had more severe preoperative pulmonary hypertension evidenced by higher pulmonary vascular resistance; however, postoperative hemodynamics were similar between groups. The authors found that patients with mixed thrombi had the most significant improvement in postoperative mean pulmonary artery pressure even when adjusting for preoperative hemodynamics.
Senior Author, Alison S. Witkin, MD, commented, “There is probably an optimal time to perform PEA, when the clot has organized and is more easily removable but prior to the onset of significant small vessel disease.” However, at present, “there is not a great way to determine clot histopathology prior to surgery.” Future investigation into noninvasive markers of thrombus chronicity may prove valuable in determining optimal timing of PEA.
Commentary by Eugene Yuriditsky, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Critical Care
Derivation and Validation of a Clinical and Endothelial Biomarker Risk Model to Predict Persistent Pediatric Sepsis-Associated Acute Respiratory Dysfunction
By James G. Williams, MD, and colleagues
Sepsis-associated acute respiratory dysfunction (SA-ARD) is associated with poor clinical outcomes in critically ill children. Whereas numerous studies have sought to develop predictive models for adult patients at risk of developing ARDS, studies in pediatric patients have been limited, and fewer studies have looked at an association between biomarkers and ARDS outcomes in children. Using a combination of clinical variables and endothelial biomarkers measured on day one, the authors of this study developed and validated a predictive model to identify patients at the highest risk of having SA-ARD on day three. Patients with persistent SA-ARD were more likely to have a pulmonary infection and experienced increased adverse outcomes, including prolonged PICU stay, increased need for mechanical ventilation and renal replacement therapy, and higher mortality. Use of integrated predictive tools could help improve early risk stratification in SA-ARD and be used to help enrich future clinical trials targeting endothelial dysfunction in pediatric sepsis.
Commentary by Kathryn Pendleton, MD, FCCP, Member of the CHEST Physician Editorial Board
CHEST® Pulmonary
High BMI and COPD Outcomes in Alpha-1 Antitrypsin Deficiency
By Michael A. Campos, MD, and colleagues
Incorporating weight management and lifestyle modification counseling into the treatment plan for patients with COPD due to alpha-1 antitrypsin deficiency (AATD-COPD) is essential, particularly given the observed inverse relationship between BMI and quality of life scores as weight fluctuates over time. Regular follow-up assessments to monitor changes in BMI and health-related quality of life would facilitate timely interventions, thereby improving respiratory health outcomes while also raising patient awareness of the impact of weight on symptomatology. Furthermore, a multidisciplinary approach involving collaboration with dietitians, pulmonary rehabilitation specialists, and weight management experts could optimize patient outcomes by addressing both the underlying disease process and the broader systemic effects associated with AATD-COPD.
Commentary by Corinne Young, MSN, FNP-C, FCCP, Member of the CHEST Physician Editorial Board