Surgical Management and Outcome of Patients With Chronic Thromboembolic Pulmonary Hypertension: Results From an International Prospective Registry

Study Questions:

What are the contemporary outcomes of pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH)?

Methods:

Twenty-six European and one Canadian center participated in a registry of consecutive patients with CTEPH referred for PEA from February 2007 to January 2009. Outcome variables included mortality, clinical benefit at 1-year follow-up, and complications from surgery.

Results:

A total of 679 patients were registered, of whom 386 (56.8%) were accepted for and underwent surgery. The median age of patients undergoing surgery was 60 years, and 54.1% were male. Previous pulmonary embolism was confirmed for 79.8% of patients. Perioperative complications occurred in 189 patients (49.2%): infection (18.8%), persistent pulmonary hypertension (16.7%), neurologic (11.2%), bleeding (10.2%), reperfusion pulmonary edema (9.6%), pericardial effusion (8.3%), need for extracorporeal membrane oxygenation (3.1%), and in-hospital mortality due to perioperative complications (4.7%). Documented 1-year mortality was 7%. Preoperative exercise capacity was predictive of 1-year mortality. Postoperative pulmonary vascular resistance (PVR) predicted in-hospital and 1-year mortality. In patients evaluated within 1 year after surgery, the median PVR had decreased from 698 to 235 dyn.s.cm-5 (95% confidence interval [CI], 640-874 and 211-255, respectively; n = 70), and the median 6-minute walk distance had increased from 362 m to 459 m (95% CI, 340-399 and 440-473, respectively; n = 168). New York Heart Association (NYHA) functional class improved, with most patients progressing from class III/IV to class I/II.

Conclusions:

The authors concluded that PEA is associated with a low in-hospital mortality rate and improvements in hemodynamics and exercise capacity.

Perspective:

CTEPH may develop in up to 4% of patients within the first 2 years after acute pulmonary embolism, but only about 70% of patients with CTEPH have had a documented pulmonary embolism, re-enforcing the need for appropriate studies in patients with pulmonary hypertension. Classic indications for PEA include NYHA class III-IV symptoms and PVR at least 240 dyn.s.cm-5, and central/proximal and minimal distal pulmonary artery occlusive disease. The mortality and outcome in the current registry approximates the results in those obtained by the top centers. Historically the mortality from PEA was related to center experience, which was not the case in this modern registry. This may be related to better surgical training and techniques, improved selection, and use of preoperative pulmonary hypertension–specific drugs so as to reduce preoperative PVR and improve right ventricular function.

Clinical Topics: Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Pulmonary Hypertension, Interventions and Vascular Medicine

Keywords: Ventricular Function, Right, Endarterectomy, Follow-Up Studies, Hospital Mortality, Pulmonary Embolism, Hypertension, Pulmonary, Canada, New York, Pulmonary Artery


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