Risk Stratification of Long-Term Outcome After Pulmonary Endarterectomy
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?
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.
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.
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.
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.
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