Next, spiral and high-resolution CT scans of the chest were performed, which excluded the presence of proximal pulmonary emboli or parenchymal lung disease. Ventilation-perfusion scans were without evidence for central or peripheral pulmonary embolism. Serologic testing for collagen vascular or autoimmune disease was negative. Finally, Swan-Ganz catheterization (Edwards Lifesciences, Irvine, CA) with pharmacologic testing was done, showing severe precapillary pulmonary hypertension with a concomitant reduction in cardiac output (mean PAP, 59 mm Hg; pulmonary vascular resistance, 1,631 dyne-s-cm~; pulmonary capillary wedge pressure, 6 mm Hg; cardiac index [CI], 1.53 L/min/m2; right ventricular ejection fraction, 6%). Based on these investigations, the diagnosis of PPH was established, and the patient was started on oral anticoagulation and long-term oxygen therapy. Furthermore, regular daily inhalations with iloprost (Ventavis, Schering AG, Berlin, Germany), a stable prostacyclin analog, were initiated as previously described. natural breast enlargement cream
As the patient reported nocturnal awakenings and excessive daytime sleepiness (Epworth sleepiness scale score of 12), full-night attended polysomnography was performed. Polysomnography was carried out with the help of a computerized system (SIDAS GS; IfM GmbH; Wettenberg, Germany) that continuously monitored the following parameters: EEG (electrodes at the positions C3/A2 and C4/A1 of the international 10-20 system), electrooculogram, electromyogram of the submental and pretibial muscles, oronasal flow (prongs), thoracoabdominal breathing movements (inductive plethysmography), oxygen saturation (Sao2) [pulse oximetry at the finger tip], and snoring (microphone). Analysis of sleep stages, arousals, and breathing while asleep was visually performed according to standard criteria. An obstructive apnea was diagnosed if complete cessation of oronasal flow occurred in the presence of thoracoabdominal breathing movements. If neither oronasal flow nor breathing efforts of the chest and abdomen could be detected, the apnea was scored as central.