title: Pulmonary Hypertension Complicating Fibrosing Mediastinitis.
abstract: Fibrosing mediastinitis is caused by a proliferation of fibrous tissue in the mediastinum with encasement of mediastinal viscera and compression of mediastinal bronchovascular structures. Pulmonary hypertension (PH) is a severe complication of fibrosing mediastinitis caused by extrinsic compression of the pulmonary arteries and/or veins.We have conducted a retrospective observational study reviewing clinical, functional, hemodynamic, radiological characteristics, and outcome of 27 consecutive cases of PH associated with fibrosing mediastinitis diagnosed between 2003 and 2014 at the French Referral Centre for PH.Fourteen men and 13 women with a median age of 60 years (range 18-84) had PH confirmed on right heart catheterization. The causes of fibrosing mediastinitis were sarcoidosis (n = 13), tuberculosis-infection confirmed or suspected (n = 9), mediastinal irradiation (n = 2), and idiopathic (n = 3). Sixteen patients (59%) were in NYHA functional class III and IV. Right heart catheterization confirmed moderate to severe PH with a median mean pulmonary artery pressure of 42 mm Hg (range 27-90) and a median cardiac index of 2.8 L/min/m (range 1.6-4.3). Precapillary PH was found in 22 patients, postcapillary PH in 2, and combined postcapillary and precapillary PH in 3. Severe extrinsic compression of pulmonary arteries (>60% reduction in diameter) was evidenced in 2, 8, and 12 patients at the main, lobar, or segmental levels, respectively. Fourteen patients had at least one severe pulmonary venous compression with associated pleural effusion in 6 of them. PAH therapy was initiated in 7 patients and corticosteroid therapy (0.5-1 mg/kg/day) was initiated in 3 patients with sarcoidosis, with 9 other being already on low-dose corticosteroids. At 1-year follow-up, 3 patients had died and among the 21 patients evaluated, 3 deteriorated, 14 were stable, and only 4 patients with sarcoidosis improved (4 receiving corticosteroids and 1 receiving corticosteroids and PAH therapy). Survival was 88%, 73%, and 56% at 1, 3, and 5 years, respectively.We found no clear clinical improvement with the use of specific PAH therapy. Corticosteroid therapy may be associated with clinical improvement, in some patients with fibrosing mediastinitis due to sarcoidosis. Although never performed for this indication, lung transplantation may be proposed in eligible patients with severe PH and fibrosing mediastinitis.
authors.affiliation: From the University Paris-Sud, Faculté de Médecine (AS, AS, XJ, OP, LS, FP, DA, RJ, EF, OS, GS, MH, DM); AP-HP, Centre de Référence de l'Hypertension Pulmonaire Sévère, Département Hospitalo-Universitaire (DHU) Thorax Innovation (TORINO), Service de Pneumologie, Hôpital de Bicêtre, Le Kremlin Bicêtre (AS, AS, XJ, LS, FP, DA, RJ, OS, GS, MH, DM); UMR_S 999, University Paris-Sud; INSERM; Laboratoire d'Excellence (LabEx) en Recherche sur le Médicament et l'Innovation Thérapeutique (LERMIT), Centre Chirurgical Marie Lannelongue, Le Plessis Robinson (AS, AS, XJ, LS, FP, DA, RJ, EF, OS, GS, MH, DM); AP-HP, Service de Radiologie, Hôpital Bicêtre, Le Kremlin-Bicêtre (OP); and Centre Chirurgical Marie Lannelongue, Service de Chirurgie Thoracique, Le Plessis Robinson, France (EF).
authors.forename: Andrei
authors.initials: A
authors.lastname: Seferian
authors.forename: Alexandru
authors.initials: A
authors.lastname: Steriade
authors.forename: Xavier
authors.initials: X
authors.lastname: Jaïs
authors.forename: Olivier
authors.initials: O
authors.lastname: Planché
authors.forename: Laurent
authors.initials: L
authors.lastname: Savale
authors.forename: Florence
authors.initials: F
authors.lastname: Parent
authors.forename: David
authors.initials: D
authors.lastname: Amar
authors.forename: Roland
authors.initials: R
authors.lastname: Jovan
authors.forename: Elie
authors.initials: E
authors.lastname: Fadel
authors.forename: Olivier
authors.initials: O
authors.lastname: Sitbon
authors.forename: Gérald
authors.initials: G
authors.lastname: Simonneau
authors.forename: Marc
authors.initials: M
authors.lastname: Humbert
authors.forename: David
authors.initials: D
authors.lastname: Montani
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D006328:Cardiac Catheterization; D005260:Female; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis / Q000209:etiology* / Q000503:physiopathology; D008297:Male; D008480:Mediastinitis / Q000150:complications* / Q000175:diagnosis; D008875:Middle Aged; D011669:Pulmonary Wedge Pressure; D012189:Retrospective Studies; D012598:Sclerosis / Q000150:complications* / Q000175:diagnosis; D014057:Tomography, X-Ray Computed