PG 2025: Pulmonary Literature Review and Interactive Complex Case Presentations (PG)-STEIGER FINALPost Graduate Course Complex Cases-Pulmonary Hypertension and Thromboembolic Disease

STEIGER FINALPost Graduate Course Complex Cases-Pulmonary Hypertension and Thromboembolic Disease - BS (1)

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This presentation by Dr. David J Steiger covers complex case management of pulmonary hypertension (PH) and thromboembolic disease, focusing on post-pulmonary embolism (PE) complications, follow-up strategies, and treatments for chronic thromboembolic disease. A case of a 37-year-old man with intermediate-high risk PE treated successfully with catheter-directed embolectomy exemplifies acute management and six-month follow-up revealing persistent symptoms without right heart failure.<br /><br />Key points include the importance of tailored anticoagulation, assessing bleeding risks, cancer screening following unprovoked VTE, and thrombophilia evaluation, which can influence treatment duration and intensity. Special considerations for women, lifestyle modifications (exercise, travel), and cardiovascular risk factor management are emphasized to optimize outcomes.<br /><br />Post-PE syndrome, affecting up to 41-45% of patients, manifests as chronic dyspnea and exercise intolerance, often related to residual pulmonary vascular obstruction (RPVO) and possibly chronic thromboembolic disease (CTED) or pulmonary hypertension (CTEPH). Right ventricular dysfunction (RVD) post-PE is a predictor of poor outcomes and persistent symptoms. Advanced therapies (systemic thrombolysis, catheter-directed therapies) can improve RV function in intermediate and high-risk PE patients, though evidence of long-term benefits remains limited.<br /><br />CTEPH remains underdiagnosed; diagnosis relies on ventilation/perfusion scanning, CT pulmonary angiography, and right heart catheterization at rest and exercise. Pathogenesis involves incomplete thrombus resolution, microvascular remodeling, and bronchial artery changes.<br /><br />Treatment for CTEPH includes pulmonary thromboendarterectomy (PTE) as the gold standard, balloon pulmonary angioplasty (BPA) for inoperable or residual disease, and medical therapy with agents like riociguat. A recent randomized trial showed BPA reduced pulmonary vascular resistance (PVR) more rapidly but with higher adverse events compared to riociguat, supporting a multimodal, individualized treatment approach often combining therapy.<br /><br />Systematic follow-up post-PE and post-intervention, including imaging and hemodynamic assessment, is crucial to detect persistent disease and guide therapy to improve survival and quality of life. The multidisciplinary team approach is essential for optimal management of these complex conditions.

Keywords

pulmonary hypertension

thromboembolic disease

pulmonary embolism

catheter-directed embolectomy

anticoagulation

post-PE syndrome

chronic thromboembolic disease

right ventricular dysfunction

pulmonary thromboendarterectomy

balloon pulmonary angioplasty