Risk Stratification of Long-Term Outcome After Pulmonary Endarterectomy

Study Questions:

What factors correlate with poor long-term outcome after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) and clinically relevant residual pulmonary hypertension (PH) post-PEA?

Methods:

A total of 880 consecutive patients from eight PH centers underwent PEA for CTEPH at Papworth Hospital from January 1997 until December 31, 2012. Patients routinely underwent detailed re-assessment with right heart catheterization and noninvasive testing at 3-6 months and annually thereafter with discharge if clinically stable at 3-5 years and not requiring pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses.

Results:

Mean age was 57 years, 53% were male, baseline mean pulmonary artery pressure (mPAP) was 47 mm Hg, pulmonary vascular resistance about 10 RU, and 6-minute walk distance 260 m, and 91% were heart failure functional class III or IV. Overall survival was 86%, 84%, 79%, and 72% at 1, 3, 5, and 10 years for the whole cohort, and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not due to right ventricular failure. At reassessment, an mPAP ≥30 mm Hg correlated with pulmonary vasodilator therapy initiation post-PEA. An mPAP ≥38 mm Hg and pulmonary vascular resistance ≥425 dyne/sec/cm-5 (5 RU) at reassessment correlated with worse long-term survival. Five patients developed recurrent PH.

Conclusions:

The data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3-6 and/or 12 months post-PEA allows stratification of patients at higher risk of dying from CTEPH and identifies a level of residual PH, which may guide the long-term management of patients post-surgery.

Perspective:

The prevalence of CTEPH after acute pulmonary embolism is about 4%, but <50% have a history of PE. Considering the high mortality of CTEPH and the excellent short- (particularly more recent) and long-term results from PEA from the UK National PH Centers, and many US centers, it is very important to screen (V/Q most sensitive) for CTEPH in all patients with significant PH. Outcome is highly dependent on patient selection and surgical techniques, which require considerable experience.

Clinical Topics: Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Cardiac Surgery and Heart Failure, Acute Heart Failure, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine

Keywords: Cardiac Catheterization, Cardiac Surgical Procedures, Diagnostic Imaging, Endarterectomy, Heart Failure, Hemodynamics, Hypertension, Pulmonary, Outcome Assessment (Health Care), Perioperative Period, Pulmonary Circulation, Pulmonary Embolism, Risk Assessment, Survival, Vascular Resistance, Vasodilator Agents


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