title: Pulmonary veno-occlusive disease: clinical, functional, radiologic, and hemodynamic characteristics and outcome of 24 cases confirmed by histology.
abstract: Pulmonary veno-occlusive disease (PVOD) is defined by specific pathologic changes of the pulmonary veins. A definite diagnosis of PVOD thus requires a lung biopsy or pathologic examination of pulmonary explants or postmortem lung samples. However, lung biopsy is hazardous in patients with severe pulmonary hypertension, and there is a need for noninvasive diagnostic tools in this patient population. Patients with PVOD may be refractory to pulmonary arterial hypertension (PAH)-specific therapy and may even deteriorate with it. It is important to identify such patients as soon as possible, because they should be treated cautiously and considered for lung transplantation if eligible. High-resolution computed tomography of the chest can suggest PVOD in the setting of pulmonary hypertension when it shows nodular ground-glass opacities, septal lines, lymph node enlargement, and pleural effusion. Similarly, occult alveolar hemorrhage found on bronchoalveolar lavage in patients with pulmonary hypertension is associated with PVOD. We conducted the current study to identify additional clinical, functional, and hemodynamic characteristics of PVOD. We retrospectively reviewed 48 cases of severe pulmonary hypertension: 24 patients with histologic evidence of PVOD and 24 randomly selected patients with idiopathic, familial, or anorexigen-associated PAH and no evidence of PVOD after meticulous lung pathologic evaluation. We compared clinical and radiologic findings, pulmonary function, and hemodynamics at presentation, as well as outcomes after the initiation of PAH therapy in both groups. Compared to PAH, PVOD was characterized by a higher male:female ratio and higher tobacco exposure (p < 0.01). Clinical presentation was similar except for a lower body mass index (p < 0.02) in patients with PVOD. At baseline, PVOD patients had significantly lower partial pressure of arterial oxygen (PaO2), diffusing lung capacity of carbon monoxide/alveolar volume (DLCO/VA), and oxygen saturation nadir during the 6-minute walk test (all p < 0.01). Hemodynamic parameters showed a lower mean systemic arterial pressure (p < 0.01) and right atrial pressure (p < 0.05), but no difference in pulmonary capillary wedge pressure. Four bone morphogenetic protein receptor II (BMPR2) mutations have been previously described in PVOD patients; in the current study we describe 2 additional cases of BMPR2 mutation in PVOD. Computed tomography of the chest revealed nodular and ground-glass opacities, septal lines, and lymph node enlargement more frequently in patients with PVOD compared with patients with PAH (all p < 0.05). Among the 16 PVOD patients who received PAH-specific therapy, 7 (43.8%) developed pulmonary edema (mostly with continuous intravenous epoprostenol, but also with oral bosentan and oral calcium channel blockers) at a median of 9 days after treatment initiation. Acute vasodilator testing with nitric oxide and clinical, functional, or hemodynamic characteristics were not predictive of the subsequent occurrence of pulmonary edema on treatment. Clinical outcomes of PVOD patients were worse than those of PAH patients.
authors.affiliation: From Université Paris-Sud 11, UPRES EA 2705, Centre des Maladies Vasculaires Pulmonaires, Service de Pneumologie et Réanimation Respiratoire (DM, LA, P. Dorfmüller, JLP, BS, CT, AR, RH, OS, XJ, FC, GS, MH); and Service de Radiologie (SM, DM); Hôpital Antoine- Béclère, Assistance Publique-Hôpitaux de Paris, Clamart. Université Paris-Sud 11, UPRES EA 2705, Service de Chirurgie Thoracique, Centre Chirurgical Marie-Lannelongue (P. Dartevelle), Université Paris-Sud, Le Plessis-Robinson. Service d'Anatomie Pathologique (P. Dorfmüller, FC), Groupe Hospitalier Pitié Salpétrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie, Paris, France.
authors.forename: David
authors.initials: D
authors.lastname: Montani
authors.forename: Lara
authors.initials: L
authors.lastname: Achouh
authors.forename: Peter
authors.initials: P
authors.lastname: Dorfmüller
authors.forename: Jérôme
authors.initials: J
authors.lastname: Le Pavec
authors.forename: Benjamin
authors.initials: B
authors.lastname: Sztrymf
authors.forename: Colas
authors.initials: C
authors.lastname: Tchérakian
authors.forename: Anne
authors.initials: A
authors.lastname: Rabiller
authors.forename: Rehan
authors.initials: R
authors.lastname: Haque
authors.forename: Olivier
authors.initials: O
authors.lastname: Sitbon
authors.forename: Xavier
authors.initials: X
authors.lastname: Jaïs
authors.forename: Philippe
authors.initials: P
authors.lastname: Dartevelle
authors.forename: Sophie
authors.initials: S
authors.lastname: Maître
authors.forename: Frédérique
authors.initials: F
authors.lastname: Capron
authors.forename: Dominique
authors.initials: D
authors.lastname: Musset
authors.forename: Gérald
authors.initials: G
authors.lastname: Simonneau
authors.forename: Marc
authors.initials: M
authors.lastname: Humbert
mesh_terms: D000328:Adult; D052006:Bone Morphogenetic Protein Receptors, Type II / Q000235:genetics; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis / Q000188:drug therapy; D008168:Lung / Q000000981:diagnostic imaging* / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009154:Mutation; D011668:Pulmonary Veno-Occlusive Disease / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000503:physiopathology*; D012129:Respiratory Function Tests; D012189:Retrospective Studies; D012737:Sex Factors; D012907:Smoking / Q000009:adverse effects; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
chemical_list: C498218:BMPR2 protein, human; D052006:Bone Morphogenetic Protein Receptors, Type II