BPA

Pulmonale Ballonangioplastie (BPA)  Seit der ersten Beschreibung in 1988 wurde die pulmonale Ballonangioplastie (BPA) anfangs nur sehr selten durchgeführt. Seit etwa 2010 haben verschiedene Arbeitsgruppen vor allem aus Japan Erfahrungen mit größeren Patientengruppen gesammelt. Seit März 2014 wird dieser spezielle Eingriff auch in der Kerckhoff-Klinik angeboten. Mittlerweile gehört unsere Abteilung zu den größten BPA-Zentren weltweit. Alle Patienten werden dabei durch ein erfahrenes und speziell-geschultes BPA-Team betreut. Mit Hilfe der BPA können weit peripher gelegene Veränderungen der Pulmonalarterien mittels eines Führungsdrahtes erreicht und anschließend mit einem Ballon aufgedehnt werden. Jedoch können dabei, in Abhängigkeit von der Schwere der Erkrankung, nur wenige Läsionen auf einmal behandelt werden. Es sind daher mehrere Sitzungen erforderlich. Die BPA wird am wachen Patienten durchgeführt. Über einen venösen Zugang in der Leiste wird eine Schleuse eingebracht, über die dann Führungskatheter und –drähte vorgeschoben werden.
Entsprechend der vorab festgelegten Zielgebiete werden die jeweiligen Segmentarterien mit einem Draht sondiert und anschließend die Veränderungen mit speziellen Ballons aufgedehnt. Hierdurch kommt es zu einer Zerreißung narbiger Fasern, die das Lungengefäß eingeengt oder verlegt hatten.
Durch die BPA verbessert sich die Durchblutung des Lungengewebes. Hierdurch verbessern sich Lungenhochdruck, Sauerstoffaufnahme ins Blut und Belastung des rechten Herzens. Dadurch nimmt die körperliche Belastbarkeit des Patienten deutlich zu.

 

 

Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience

Abstract

Balloon pulmonary angioplasty (BPA) is an emerging treatment for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH).

We report on a prospective series of 56 consecutive patients who underwent 266 BPA interventions (median, five per patient) at two German institutions. All patients underwent a comprehensive diagnostic work-up including right heart catheterisation at baseline and 24 weeks after their last intervention.

BPA resulted in improvements in WHO functional class, 6 min walk distance (mean change, +33 m), right ventricular function and haemodynamics, including a decline in mean pulmonary artery pressure by 18% and in pulmonary vascular resistance by 26%. Procedure-related adverse events occurred in 9.4% of the interventions. The most common complications were related to pulmonary vascular injury and consecutive pulmonary bleeding. Most of these events were asymptomatic and self-limiting, but one patient died from pulmonary bleeding, resulting in a mortality rate of 1.8%.

BPA resulted in haemodynamic and clinical improvements but was also associated with a considerable number of complications, including one fatal pulmonary bleeding. As the effects of BPA on survival are unknown, randomised controlled outcome trials comparing BPA with approved medical therapies in patients with inoperable CTEPH are required to allow for appropriate risk–benefit assessments.

BPA improves haemodynamics and exercise capacity in patients with inoperable CTEPH but complications are not uncommon http://ow.ly/mMYY30b1rch

 

CTEPH

CTEPH; Gruppe 4 nach WHO

 most experts agree that approximately 4% to 5% of all patients who have an acute episode of pulmonary embolism (PE) will continue to develop CTEPH. Based on an incidence rate of about 0.1% for acute PE, this translates into a CTEPH incidence of approximately 10,000 to 15,000 annually in the United States alone. Furthermore, there are patients with CTEPH who have no history of prior PE or deep vein thrombosis, adding to the estimated number. Despite these facts, the disease remains significantly underdiagnosed, and currently there are only about 300 PTEs performed nationwide, the majority of which are done at the University of California, San Diego (UCSD) Health System. The technical aspects of the procedure can be somewhat challenging and require meticulous

Meistens ist die CTEPH mit einer vorausgegange- nen venösen Thromboembolie assoziiert. So fand sich in einer internationalen prospektiven CTEPH- Datenbank bei 74,8% der CTEPH Patienten in der Vorgeschichte eine akute Lungenembolie, und bei 56,1 % eine tiefe Beinvenenthrombose

Die chronisch thromboembolische pulmonale Hypertonie (CTEPH) ist eine seltene, schwere Erkrankung. Ursächlich sind Blutgerinnsel, die meist aus den Venen der unteren Körperhälfte, mit dem Blutstrom in die Lunge eingeschwemmt werden (= akute Lungenembolie). Diese werden bei manchen Patienten zu Narbenmaterial umgebaut, das die Lungengefäße verlegt. In der Folge entsteht ein erhöhter Druck in den Lungenarterien (= pulmonale Hypertonie), was zu einer zunehmenden Belastung des rechten Herzens führt. Man geht heutzutage davon aus, dass bei bis zu 5 % der Patienten, die eine akute Lungenembolie überleben, die Blutgerinnsel nicht aufgelöst werden, sondern zu Narben- oder Bindegewebe umgebaut werden und sich dann im weiteren Verlauf eine CTEPH entwickelt.

Symptome Üblicherweise verspüren die meisten Patienten eine im Verlauf zunehmende Luftnot bei Belastung. Da die Beschwerden recht unspezifisch sind, vergehen zwischen dem Auftreten der ersten Symptome bis zur endgültigen Diagnosestellung durchschnittlich 14 Monate. Da sich viele Patienten dann in einem bereits fortgeschrittenen Krankheitsstadium befinden, sollte bei unklarer Atemnot, insbesondere nach stattgehabter Lungenembolie, eine zügige und exakte Diagnostik erfolgen, um die CTEPH nachzuweisen oder auszuschließen.

Fear…

…jeden Tag der letzten 3 Wochen hatte ich Angst, Angst, dass ich es nicht schaffe, Angst, dass etwas schief geht, Angst, mein Kind „allein“ zu lassen, obwohl Papa (der muss arbeiten), Nanny und Grosseltern (die leider immer doch was finden, was sie machen müssen) da sind, Angst hat sich manifestiert…und ich werde sie nicht los. Sicher, Respekt zu haben ist gut, aber Angst frisst einen auf, macht alles unerträglich und der Kopfschmerz ist da, täglich, wird stärker und in den Momenten des „Guten“ leichter…Dazu kommt noch eine komische Erkältung, mein rechtes Ohr ist zu, schlucken tut „weh“, ein Kratzen im Hals…eine dumpfe bleierne Müdigkeit im ganzen Körper, die es unmöglich macht tatkräftig zu sein und motiviert…sie hindert, behindert, macht steif und starr…Die Yogamatte liegt da, ich „sollte“ Übungen machen, aber ich kann nicht, wie ein Flimmer vor meinen Augen, bin ich einfach nur müde. Ich würde so gerne einmal wieder richtig schlafen. 12h am Stück, ich glaub danach wäre ich ein „neuer“ Mensch. Doch die Hitze der vergangenen beiden Nächte erschwerten jeglichen guten Schlaf. Die Schlaftablette am Freitag hab ich zu spät genommen um halb 1 und um viertel nach 8 war die Nacht rum…doch ich hätte noch weitergeschlafen, wenn keine Bauchspritze gewesen wäre…
Morgen gg. 11 Uhr ist es soweit und um 13 Uhr sollte alles gut gegangen sein. Egal ob 2 oder 3 Segmente, wichtig ist, dass ich es heil überstehe ohne Blut husten, ohne Wasser auf der Lunge…vor dem 2. habe ich nicht so große Angst, es ist mehr die Angst des Blut hustens, denn ich habe schon ein gutes Lungenvolumen…bzw. Sauerstoffsättigung in Ruhe, da denke ich wird meine Lunge jetzt nicht überrascht sein, von dem was noch geöffnet wird auch wenn es mir immens helfen kann in der Bewegung. In 24 könnte ich schon meinen Druckverband haben und lächeln…dann wäre die Angst erstmal wieder verflogen.

 

What the …. I am doing here?

unbelivable…sitting here and waiting for my 4th operation, already but still 3 after this one to go through…so it turns our really well when I consider that after three interventions I am feeling that better – on the other hand side, I am freaking out, just thinking about what will be if not…of course I can deal with the circumstance, but is this how I pictured my life before? could happen…Having a strange allergy now on my hands, might be nothing to do with the medicine I am taking, as it seems familiar to me, I think I had them twice already, but not that strong and lasting…Sun is shining, my friend Esther is coming later to visit me, I went for a meditation stretching in the park this morning after a short sleep this night and another one the night before with nightmares…If there is somebody, either god or the universe or whom ever who is taking care about us, I pray that he or she will let me survive in a happy way! Of course I would love to deal now and tell what all I am doing, if operation goes well…I know now 100% that my illness turned out because of my high psychical stress lever and under the pressure I am being / was during the last 10-20 years…always wanted to be successful, damn, I was and still I am!  But is it worth if this is the outcome?

 

every single day time runs to fast for everybody…

Sometimes you barely notice you’re living with chronic stress because you’ve learned to adapt to it. Feeling tired, distracted, irritated, and plagued by a nagging sense that time is running out starts to feel normal. You shrug off the way life keeps speeding up and accept that work pressures are necessary to get ahead in your career. Yet living in a state of overdrive is anything but normal, and it actually causes more harm than you may realize.

As for me living with this illness it can be a killer. I always have to remind myself: stay calm, be patient, go slowly, don´t rush or even run, take enough time to come from one point to the other…slow down! But often there are situations in everybody´s lifes as well in mine, which you can´t control or plan – it is just the worker who comes a little bit to late and then you will leave the house to pick up your son from kindergarten and then you notice that in front of your parking place a neighbours car parks so you can not leave.How many minutes I have to plan more into my life to not get stressed? I mean you all know this feeling and it stress you and me. For you it is might be a way into a problem or you just be stressed all your life but for me it is so dangerous as I am not allowed to come under 90…

good days!!!

Yeah, it is always the same after rain there will be sunshine, and after sun, rainy days will follow. I am still in heaven as today it is a lucky day. I went up the stairs without oxygen, slowly and breathing through the nose, did some cloth arrangements in my son´s room and went downstairs with a heavy box. I didn’t felt that much „stress“ or had the feeling I can’t breath and by checking my values it was confirmed! 92% oxygen and 82 heart rate, after sitting two minutes 98% and 75 heart rate – chaka! So what I am learning at the moment, is breathing via my nose, in AND out and doing everything a little slower and with patience. Despacito y lento are my words for 2018! Today I can say it with a smile and of course I want to keep this happy feeling as I know there are days, I don´t feel well. Even as today i feel a bit dizzy and evil. I didn’t´t had this the last weeks. I am trying to find out, why it happens sometimes, as tonight I slept well and 8 hours. I took my pill (Adempas) very early this morning around 8.45am – usually I do an hour later. And I was drinking a strong green fresh tea…might be the combination of my green tea and the medicine don´t fit together…? And I had breakfast very early around 9.30am with muesli, yoghurt and fruits…

Also I received some good news we have to proof, that vueling offers oxygen  on board for free (!?!) which means I could fly from Ibiza to Frankfurt via Barcelona and then home direct (as direct flights starting around 25th march due to easter holidays). All research costs a lot of time and always depends on the people you are talking with or emailing with but I have to say that so far my experiences are very good and I receive a lot of help and support from strangers. Of course, we could say it is their job, but they really try to help. That´s why I also did a check off on my to do list finally, as I sent a healthy Tea box to a woman called  Mrs. Waelde, as she was an amazing help through all my complications to get my prescriptions for Adempas and was supporting us during the adaption while I was travelling between Munich, Bad Nauheim, Ulm and Ibiza. Also a little present for the lovely lady from Vitalaire as she always did me a favour regarding my oxygen machines. I have a few more on my list I am grateful for, so not finished yet with saying „thank you“.

my second BPA

on monday the 5th february after a sleepless night I was looking forward to the second intervention. Even I was too tired and not feeling „happy“ I was calm, I was „fine“ with me. I had no pain when they placed my catheter, 2nd step went well…then the clock was running and it was already 10.45am – I was asking if all is good…? At 11.15am they were surprised I am still in my room, in the meanwhile I did some breathing exercises, which went better than the last days. I really was totally calm…Then at 11.50am I was nervous, as I took my „caughing pill“ already as commanded at 9.15am – same moment the „driver“ of my bed came and brought me downstairs. Same place like last time I was waiting in front of the same Cardiac catheter room.  Good sign, I was keeping the love heart from my son and his pictures with me. Then Anja, the amazing nurse from last time, when I had to caugh blood passed by, stopped and smiled. Now I even felt more relaxt, as I felt save, even if I knew she will not be all the time with me, I gave me a good feeling. Another nurse, super sympathic, did an amazing job by setting my catheter left side. No pain, I even didn´t noticed that she was pulling it in! Third milestone on they way to the operation table went well! And this time I had my stick with my music Deva Prenal „Love is Space“.

It was good to see well known faces, as the „main“ nurse was today as well with us (Anja had to leave after preparation) and they were talking with me, like we would have a coffee, about Meditation, the stressful life of being a mum, wife and working woman…I was prepared, lying on a heated small bed, palms upwards, my feet falling left and right side, I tried to lay down as comfortable as possible. My music was on and then at 12.15 the doctors came in and started. The only real pain I felt, was the cut in the groin to get in with all instruments. I received a light drug 1:1 – I was remembering from the first one! And all started…I trusted again and I felt very safe and „home“. It took a long time this time, as they were very enthusiastic but also very zurückhaltend this time. Prof. Dr. Ghofrani were also watching, when they were operating in the first segment number 9 today and it turned  out very difficult as all Gewebe war verklebt. They had to do it slowly, starting with a ballon size 1 going up to 3 to make sure, they will not break any vessel today.

 

 

a hopeless day…

I was just freaking out on saturday morning, I was crying the whole way to the clinic…silent and loud, I didn’t wan´t to leave my son again, I couldn’t´t imagine I will do the intervention again, even I have beeing so brave the weeks before. I was just afraid. It came when I was packing all together and I noticed the distance between my son and me as he also was preparing himself for a few days without mum and he prefers to create space between us, not really mental, it is more physically. He don´t want to hug, that I talk to him, he is going on distance and this hurts! Of course I know him in best hands with my parents, but it is hard to leave him after all what happened in august and especially October and November. He is a sensitive character as I am but he is it really, 100%! So on our way to the clinic I gave up in hoping, praying and believing, especially after our car broke down last eve, we managed it to reach the house of my parents after our ski holiday and then my husband had to react and organising all to make sure, we have a car next day and our car will be towed away. But worth thing: he got another attack of Toxoplasmosis in his eye so he went „immediately“ to emergency. I am sure he was noticing it since a week but didn’t want to take action during our amazing time in the snow in Austria together. They have been super unfriendly to him, why he is coming on a friday evening and told him to look for his regular doctor. Are they kidding? He is in Barcelona and not an emergency doctor! So in the end we were driving to Bad Nauheim and arrived at 3.30pm. I was shaking, it is always the same, if I walk along this street. First I thought because only of the cold, but now I know it is my impression to show that I am afraid…The hours in the car, I felt lonely, left alone, I couldn’t except that all is like it turns out, as well as Daniel´s Dad had to check his „prostata“ as his sum was higher even as he was operated 5 years ago. So I felt into an empty space, it was not dark, but hopeless! I had the very first time the feeling I give up…I had no Power for a few hours and also next day I wasn’t that good. I didn’t want to talk or think about my next BPA…I was worrying, as I had the feeling, that after all these negative successions my forecast for the BPA was not good. But then it became better…The  blood collection went super well – first step. Sunday we only were waiting for monday and they told us, monday at 10.15am we start. Juppie!

 

Doctor’s visits

I was sitting in front of him and said: I think I am just stressed, was a lot the last month. He was looking at me, checked my finger with a oxygen meter. I saw this „thing“ the first time in my life deliberately. And now it is my „life insurers“…His reaction was not nervous, but he said this is too low,it was 92 and he said his is better even he is a smoker. We made a ECG, was fine…what do I know about it, so he sent me to a lung function test, but as we live in Ibiza all takes longer…also I had to come back for a blood test.

 

Summer 2017…displacement

After my last wedding in June, which one was horrible and I offered them before that They get their money back or anorher team member will be at their wedding, as we weren’t compatible. No respect and I knew it that we would be responsabel for things we haven’t been involved…But, hey, it is more important to say the owner of the company was my wedding planner instead of taking advise from us. When I left the party after all was finished from our side and they finally payed us, I was angry, nearly crying, I was so exhausted when I was driving home. Disapointed. I decided all the weddings during the upcoming month will be realized by one of my team members, as they were still motivated, passinonated…but I was just empty. So the next weeks were beautiful, but I could feel, that my breathing was still worse, I thought in may I only have to go through june and all will be fine. I am not sure but it was end of may when my pilates teacher told me I am having issues inside and don’t speak about them with the persons belonging too and she was hunting me through my garden, to get the shit out. I was running, but nearly collapsing. We did this a second time, but then she stopped and we started meditation to calm me down. Of course I had a lot of things inside I was taking with me or when I was talking to my partner I didn’t saw them that difficult anymore and went on. I always thougt I can not breath because I was running through life since ages, and I never stopped, nore in my pregnancy and when my son was born I started a new business. I never will forget that he was in my arms or on my belly, my notebook on my knees and the movil in one hand and with the same I tried to make notes. How stupid could I be? Unbelievable and these are the moments in life I regrett as I am not a patience person and even was it less in winter 2014/15! What a unresponsable mum? Since he was born or might be even before when he was in my belly growing I was „nervous“…I was feeling an inner unrest. Hectic. No long deep breathes, short and shallow breathing. In June 2017 I woke up in the nights and had the feeling I can not breath anymore, I had to sit up, I took a while till it was getting better, sometimes not. I tried to get more air through my mouth, deep…but it stopped in my breast and I was afraid…but next morning life went on. No break. During the day I always felt stressed, running from one point to the other, always in a rush. I was incredibly tired, unconcetrated…I could not go upstairs without maling a quick break and try to breath. All was heavy for me, bringing my son to bed cost me a lot of energy, to carry him – impossibly…I went to the doctor finally after my bad in july.