This site is intended for US Healthcare Professionals

Type Size: A A A
For US Healthcare Professionals Only  |  For Non-US Residents

CTEPH Myths:
Learn common myths and realities about CTEPH and its treatment

Download now

Share

Myth: PEA Surgery Has a High Mortality Rate

William Auger, MD, dispels the myth that pulmonary thromboendarterectomy surgery has a high mortality rate, pointing out that experienced centers have been able to achieve mortality rates of <5%.

  • William Auger, MD, dispels the myth that pulmonary thromboendarterectomy surgery has a high mortality rate, pointing out that experienced centers have been able to achieve mortality rates of <5%.

    William Auger, MD, dispels the myth that pulmonary thromboendarterectomy surgery has a high mortality rate, pointing out that experienced centers have been able to achieve mortality rates of <5%.
    Click to Play Video

  • Richard Channick, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) is still an experimental technique in CTEPH.

    Richard Channick, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) is still an experimental technique in CTEPH.
    Click to Play Video

  • Nick H. Kim, MD, dispels the myth that very ill patients cannot be considered for pulmonary thromboendarterectomy surgery, the only potentially curative treatment for CTEPH.

    Nick H. Kim, MD, dispels the myth that very ill patients cannot be considered for pulmonary thromboendarterectomy surgery, the only potentially curative treatment for CTEPH.
    Click to Play Video

  • Paul Forfia, MD, dispels the myth that the ventilation/perfusion scan is contraindicated in patients who have pulmonary hypertension, arguing that it is an essential screening tool in CTEPH diagnosis.

    Paul Forfia, MD, dispels the myth that the ventilation/perfusion scan is contraindicated in patients who have pulmonary hypertension, arguing that it is an essential screening tool in CTEPH diagnosis.
    Click to Play Video

  • Paul Forfia, MD, dispels the myth that if a patient’s pulmonary vascular resistance is greater than 1000 dyn∙s∙cm −5, he or she cannot be a candidate for pulmonary thromboendarterectomy (PTE, also known as PEA) surgery.

    Paul Forfia, MD, dispels the myth that if a patient’s pulmonary vascular resistance is greater than 1000 dyn∙s∙cm−5, he or she cannot be a candidate for pulmonary thromboendarterectomy (PTE, also known as PEA) surgery.
    Click to Play Video

  • Victor F. Tapson, MD, dispels the myth that PTE (also known as PEA) surgery can’t be done in obese patients, pointing out that obesity does not by itself disqualify a CTEPH patient as a candidate for PTE surgery.

    Victor F. Tapson, MD, dispels the myth that PTE (also known as PEA) surgery can’t be done in obese patients, pointing out that obesity does not by itself disqualify a CTEPH patient as a candidate for PTE surgery.
    Click to Play Video

  • Ivan Robbins, MD, dispels the myth that a ventilation/perfusion scan showing perfusion defects is sufficient to diagnose CTEPH. Definitive diagnosis requires RHC and pulmonary angiography.

    Ivan Robbins, MD, dispels the myth that a ventilation/perfusion scan showing perfusion defects is sufficient to diagnose CTEPH. Definitive diagnosis requires RHC and pulmonary angiography.
    Click to Play Video

  • Richard Channick, MD, dispels the myth that medical therapy can be used to delay or replace PTE surgery, urging that CTEPH patients with operable disease be referred for PTE surgery without delay.

    Richard Channick, MD, dispels the myth that medical therapy can be used to delay or replace PTE surgery, urging that CTEPH patients with operable disease be referred for PTE surgery without delay.
    Click to Play Video

  • William Auger, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) cannot be performed in older patients.

    William Auger, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) cannot be performed in older patients.
    Click to Play Video

  • Victor F. Tapson, MD, dispels the myth that a patient who recovers from an acute pulmonary embolism cannot go on to develop CTEPH.

    Victor F. Tapson, MD, dispels the myth that a patient who recovers from an acute pulmonary embolism cannot go on to develop CTEPH.
    Click to Play Video

  • Nick H. Kim, MD, dispels the myth that computerized tomographic pulmonary angiography has become so sophisticated that it can be used as a screen instead of a V/Q scan to rule out CTEPH.

    Nick H. Kim, MD, dispels the myth that computerized tomographic pulmonary angiography has become so sophisticated that it can be used as a screen instead of a V/Q scan to rule out CTEPH.
    Click to Play Video

  • Ivan Robbins, MD, dispels the myth that once PH is confirmed by RHC, there is no need to perform a V/Q scan, arguing that a V/Q scan remains essential to screen for CTEPH.

    Ivan Robbins, MD, dispels the myth that once PH is confirmed by RHC, there is no need to perform a V/Q scan, arguing that a V/Q scan remains essential to screen for CTEPH.
    Click to Play Video

  • Myth: PEA Is Still Experimental

    Richard Channick, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) is still an experimental technique in CTEPH.
    Click to Play Video

  • Myth: Very Ill Patients Cannot Be Considered for PEA Surgery

    Nick H. Kim, MD, dispels the myth that very ill patients cannot be considered for pulmonary thromboendarterectomy surgery, the only potentially curative treatment for CTEPH.
    Click to Play Video

  • Myth: A V/Q Scan is Contraindicated in Patients with PH

    Paul Forfia, MD, dispels the myth that the ventilation/perfusion scan is contraindicated in patients who have pulmonary hypertension, arguing that it is an essential screening tool in CTEPH diagnosis.
    Click to Play Video

  • Myth: PEA Surgery Has a High Mortality Rate

    William Auger, MD, dispels the myth that pulmonary thromboendarterectomy surgery has a high mortality rate, pointing out that experienced centers have been able to achieve mortality rates of <5%.
    Click to Play Video

  • Myth: If PVR Is Too High, You Can’t Do PEA

    Paul Forfia, MD, dispels the myth that if a patient’s pulmonary vascular resistance is greater than 1000 dyn∙s∙cm−5, he or she cannot be a candidate for pulmonary thromboendarterectomy (PTE, also known as PEA) surgery.
    Click to Play Video

  • Myth: PEA Surgery Can’t Be Done in Obese Patients

    Victor F. Tapson, MD, dispels the myth that PTE (also known as PEA) surgery can’t be done in obese patients, pointing out that obesity does not by itself disqualify a CTEPH patient as a candidate for PTE surgery.
    Click to Play Video

  • Myth: A V/Q Scan Is Enough to Make a Definitive Diagnosis

    Ivan Robbins, MD, dispels the myth that a ventilation/perfusion scan showing perfusion defects is sufficient to diagnose CTEPH. Definitive diagnosis requires RHC and pulmonary angiography.
    Click to Play Video

  • Myth: I Can Use Medical Therapy to Delay or Replace PEA Surgery

    Richard Channick, MD, dispels the myth that medical therapy can be used to delay or replace PTE surgery, urging that CTEPH patients with operable disease be referred for PTE surgery without delay.
    Click to Play Video

  • Myth: PEA Cannot Be Performed in Older Patients

    William Auger, MD, dispels the myth that pulmonary thromboendarterectomy (PTE, also known as PEA) cannot be performed in older patients.
    Click to Play Video

  • Myth: Recovery From Acute PE Excludes CTEPH

    Victor F. Tapson, MD, dispels the myth that a patient who recovers from an acute pulmonary embolism cannot go on to develop CTEPH.
    Click to Play Video

  • Myth: CT Pulmonary Angiography Can Be Used to Rule Out CTEPH

    Nick H. Kim, MD, dispels the myth that computerized tomographic pulmonary angiography has become so sophisticated that it can be used as a screen instead of a V/Q scan to rule out CTEPH.
    Click to Play Video

  • Myth: If Signs Point to PH, There Is No Need for a V/Q Scan

    Ivan Robbins, MD, dispels the myth that once PH is confirmed by RHC, there is no need to perform a V/Q scan, arguing that a V/Q scan remains essential to screen for CTEPH.
    Click to Play Video

Hello, I'm Bill Auger. I'm a Professor of Clinical Medicine and Director of Academic Affairs for the Pulmonary Thromboendarterectomy Program at the University of California, San Diego.

In this brief presentation, I'm going to discuss the essential role of 2 diagnostic techniques--the ventilation/perfusion or V/Q scan, and right heart catheterization--in the diagnosis of chronic thromboembolic pulmonary hypertension or otherwise known as CTEPH.

Appropriate use of these 2 tools allows physicians to effectively differentiate the type of pulmonary hypertension faced, and to plan the optimal treatment course.

Very briefly, Chronic Thromboembolic Pulmonary Hypertension, or CTEPH, is defined as mean pulmonary arterial pressure of at least twenty-five millimeters of mercury and a pulmonary capillary wedge pressure of no more than fifteen millimeters of mercury in the presence of multiple chronic or organized occlusive thrombi in the elastic pulmonary arteries (that is, in the main, lobar, segmental or subsegmental vessels) after at least three months of effective anticoagulation.

So let's take a look at these two modalities in turn, and discuss why they are so important in CTEPH.

According to the 5th World Symposium on Pulmonary Hypertension, the V/Q scan is the preferred and recommended screening test for chronic thromboembolic disease in patients with pulmonary hypertension, and it should be viewed as an essential initial first step in the diagnosis of CTEPH. Computed tomography pulmonary angiogram (or CTPA) for screening may lead to potential misdiagnosis of PAH and underdiagnosis of CTEPH, including patients with distal disease.

As we begin talking about the V/Q scan, let's quickly review the mechanics of ventilation/perfusion imaging.

These two separate scans are used to evaluate the circulation of air and blood in the lungs, and are produced by use of mildly radioactive isotopes in conjunction with scintigraphy.

The ventilation scan detects radioactive gas inhaled by the patient and shows the distribution of ventilation. The perfusion scan detects radioactive albumin (which is intravenously injected prior to the scan) and shows the distribution of pulmonary perfusion. The two scans are typically performed together during a single visit.

The World Symposium on Pulmonary Hypertension recommends the ventilation/perfusion scan over CTPA, because the V/Q scan is far more sensitive. Tunariu and colleagues reported CTPA sensitivity for detecting CTEPH of 51%. The same authors reported V/Q sensitivity greater than ninety-six percent, and they conclude that a normal ventilation/perfusion scan can effectively rule out CTEPH. Conversely, an abnormal V/Q scan is suggestive of CTEPH—even when a CT scan is negative.

Yet, despite widespread and consistent recommendations that V/Q scanning be used to screen for CTEPH, underutilization of V/Q scans in screening PH patients invites potential misdiagnosis of pulmonary arterial hypertension.

To help contextualize the gap between recommendations and practice, let's look at the recent Pulmonary Arterial Hypertension-Quality Enhancement Research Initiative, or PAH-QuERI study.

PAH-QuERI looked at two essential components:

First, quality enhancement:

In this part, researchers determined the diagnostic approach used in patients with PAH and current variations from published 2004 ACCP guidelines with the intent of implementing feedback-based interventions to close care gaps;

And second, research:

This component monitored PAH management and outcomes in real-world practice and analyzed the data.

So, data from the PAH-QuERI showed that 43% of the PAH patients enrolled in this registry had not received the V/Q scan as part of their diagnostic workup for pulmonary hypertension.

Why was that? The single most commonly given answer was that a V/Q scan isn't relevant as part of the PH workup. That points to a need to increase awareness of the relevance of V/Q scanning to PH patients.

A positive V/Q scan should be followed by further diagnostic studies--consistent with the diagnostic algorithm--because the V/Q scan may underestimate the burden of vascular obstruction.

The key takeaway regarding V/Q scans in PH is that every patient in whom PH is either confirmed or highly suspect should have a V/Q scan to exclude CTEPH. CTEPH is the only potentially curable form of PH, via pulmonary endarterectomy surgery (also referred to as pulmonary thromboendarterectomy). So the V/Q scan is essential to ensure that clinicians identify operable CTEPH.

To confirm a diagnosis of PH, right heart catheterization is mandatory.

In CTEPH, the right heart catheterization has additional importance, as pulmonary vascular resistance is an important determinant of prognosis and the risk associated with PEA surgery.

Right heart catheterization will show whether CTEPH, as we defined it hemodynamically at the beginning of this presentation--which is a mean PA pressure of >25 mmHg and a pulmonary capillary wedge pressure of <15 mmHg--is present.

Here you will see standard approaches for catheter access to perform a right heart catheterization: via the interior jugular vein, the basilic vein, or the femoral vein.

I hope we've helped you better understand the seminal role of the V/Q scan in the appropriate diagnosis of CTEPH. We also hope that you'll watch the other videos in this series to learn more about CTEPH.

Thank you for visiting CTEPH.com and watching this educational video. Please bookmark this site and check back frequently, as we'll continue to update CTEPH.com with new content.