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Correspondence |

Dramatic Functional Improvement Following Bariatric Surgery in a Patient With Pulmonary Arterial Hypertension and Morbid Obesity FREE TO VIEW

Salvador Díaz-Lobato, PhD; Javier Gaudó Navarro, PhD; Esteban Pérez-Rodríguez, PhD
Author and Funding Information

Pneumological Departament Ramón y Cajal Teaching Hospital Madrid, Spain

Correspondence to: Salvador Díaz Lobato, PhD; e-mail: sdiazlobato@gmail.com


The authors have no conflicts of interest to disclose.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/misc/reprints.shtml).


Chest. 2008;134(3):670. doi:10.1378/chest.08-1154
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To the Editor:

We have read with great interest the article recently published in CHEST (March 2008) by Mathier et al,1 who report a case of a morbidly obese patient with idiopathic pulmonary artery hypertension (PAH). We do not agree with some aspects related to the management of the patient, and we would like to discuss them.

A morbid patient (body mass index of 46.3 kg/m2) with sleep apnea syndrome treated successfully with continuous positive airway pressure and oxygen therapy is presented. There is no comment about the functional respiratory status of the patient. We do not know if he had respiratory insufficiency. We do not know anything about the Pco2 level. Was he hypercapnic?

There is no comment about the sleep study. We do not know if the patient had obesity hypoventilation syndrome associated with sleep apnea syndrome. If so, the patient would have been treated with nocturnal noninvasive ventilation. In this sense, if the patient has not been treated correctly and there is respiratory insufficiency, how can the authors establish a diagnosis of idiopathic PAH? Hypoxemic stimulus would completely justify PAH.2

After bariatric surgery, the patient had a substantial decrease in weight and body mass index and a dramatic increase in 6-min walk test distance. However, once again we do not know anything about the improvement in the sleep study results of the patient. Perhaps the improvement in functional status of the patient was related to the weight loss?

We were also surprised by the treatment prescribed by authors. We think that there are insufficient data related to left ventricular diastolic dysfunction, which is commonly associated with severe obstructive sleep apnea, and can represent a contraindication for using these new vasodilators. In fact, by using bosentan, mean pulmonary artery pressure got worse initially up to 53 mm Hg.3,4 In addition, portal hypertension, renal failure, and thyroid disorders should be ruled out to apply the term of idiopathic PAH in this case. Finally, it seems that there are no clear criteria in terms of using combination therapy. We do not understand why a second or a third drug are added because the results obtained compared to monotherapy are probably very similar. It would be also interesting to have more data about the dosages used and decision making in the future.5 We think there are doubts enough to consider adequate the management of the patient and the treatment prescribed by authors.

Mathier MA, Zhang J, Ramanathan RC. Dramatic functional improvement following bariatric surgery in a patient with pulmonary arterial hypertension and morbid obesity. Chest. 2008;133:789-792. [PubMed] [CrossRef]
 
Kessler R, Chaouat A, Schinkewitch PH, et al. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutives cases. Chest. 2001;120:369-376. [PubMed]
 
Romero-Corral A, Somers VK, Pellikka P, et al. Decreased right and left ventricular myocardial performance in obstructive sleep apnea. Chest. 2007;132:1863-1870. [PubMed]
 
Fung JWH, Li TST, Choy DKL, et al. Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction. Chest. 2002;121:422-429. [PubMed]
 
Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest. 2007;131:1917-1928. [PubMed]
 

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References

Mathier MA, Zhang J, Ramanathan RC. Dramatic functional improvement following bariatric surgery in a patient with pulmonary arterial hypertension and morbid obesity. Chest. 2008;133:789-792. [PubMed] [CrossRef]
 
Kessler R, Chaouat A, Schinkewitch PH, et al. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutives cases. Chest. 2001;120:369-376. [PubMed]
 
Romero-Corral A, Somers VK, Pellikka P, et al. Decreased right and left ventricular myocardial performance in obstructive sleep apnea. Chest. 2007;132:1863-1870. [PubMed]
 
Fung JWH, Li TST, Choy DKL, et al. Severe obstructive sleep apnea is associated with left ventricular diastolic dysfunction. Chest. 2002;121:422-429. [PubMed]
 
Badesch DB, Abman SH, Simonneau G, et al. Medical therapy for pulmonary arterial hypertension: updated ACCP evidence-based clinical practice guidelines. Chest. 2007;131:1917-1928. [PubMed]
 
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