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Case study

Surgery relieves pulmonary hypertension symptoms

An inflamed artery in a tissue sample from a patient suffering from pulmonary hypertension. Photo: Flickr / Pulmonary Pathology
Bariatric surgery relieves symptoms of idiopathic pulmonary arterial hypertension in patient far better than traditional therapy

Surgeons have reported that bariatric surgery has relieved the symptoms of a woman’s idiopathic pulmonary arterial hypertension (IPAH), in a case study published in Diabetes Care

The patient, a 48-year-old morbidly obese woman, saw a dramatic improvement in her IPAH symptoms 20 months after receiving a Roux-en-Y gastric bypass, despite a relatively modest drop in her weight. The authors of the case study hypothesised that the improvement in her metabolic hormones led to the amelioration of her IPAH symptoms.

“This single patient represents an experiment in nature in which modest improvement in morbid obesity through bariatric surgery in IPAH correlated with marked rapid improvement in pulmonary vascular disease severity, despite no change in IPAH-directed therapy,” they wrote.

They also noted that the improvement in her symptoms was more significant than that seen even after years of traditional IPAH therapy.

Before the operation, the patient had a BMI of 54, and had a New York Heart Association classification of III, implying significant functional limitation caused by heart failure. She also had mild sleep apnoea, and was taken bosentan and sildenafil for her IPAH.

Within one month of her operation, she reported that she was more able to perform exercise, and her New York Heart Association classification dropped to II. An echocardiograph showed that her right ventricular function and right heart catheterisation had improved significantly, leading to an increase in cardiac output.

Twenty months after the operation, her weight had dropped by 43kg, lowering her BMI to 41. Over the same period, her free fatty acid levels fell from 1.02 to 0.86 mmol/L, and her LDL was reduced from 143.8 to 109.6 mg/dL. At the same time, her HDL rose from 47 to 63 mg/dL and her triglycerides from 56 to 67 mg/dL.

The authors said that her haemodynamic improvement correlated with the improvement in her metabolic markers and fatty acid levels. However, adiponectin, ghrelin, and resistin saw significant variability over the course of follow-up were not correlated with her haemodynamic improvement.

“These data point to insulin resistance, lipid metabolism, and possibly, leptin as potential mediators of pulmonary vascular disease,” the authors write, “and suggest that adiponectin, ghrelin, and resistin may be less important to human IPAH development.”

The experience of the patient, they said, “illustrates new potential pathways of importance in metabolic regulation that may have therapeutic potential for this devastating disease.”

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