Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

doi:10.1016/0003-4975(96)00169-5

The Annals of Thoracic Surgery

Volume 61, Issue 6, June 1996, Pages 1788-1792

https://doi.org/10.1016/0003-4975(96)00169-5 Get rights and content

Background

In patients with chronic thromboembolic pulmonary hypertension, acute and striking decreases of pulmonary artery pressures and vascular resistance can be achieved by pulmonary thromboendarterectomy. In this study, the long-term effects of pulmonary thromboendarterectomy on hemodynamic indices and right ventricular function were investigated.

Methods

Sixty-five patients (31 women and 34 men; mean age, 47 ± 17 years; range, 19 to 69 years; New York Heart Association [NYHA] functional class II, n = 3; class III, n = 38; class IV, n = 24) were reassessed 13 to 48 months (mean, 27 months) after pulmonary thromboendarterectomy. Measurements are reported as mean ± standard deviation.

Results

All patients reported a significant improvement of symptoms: 46 patients were in NYHA functional class I, 16 patients in class II, and 3 patients in class III. Mean pulmonary vascular resistance was significantly reduced compared with preoperative and postoperative values (preoperative: 1,015 ± 454 dynes · s · cm⁻⁵; post-operative: 322 ± 154 dynes · s · cm⁻⁵; follow-up: 198 ± 72 dynes · s · cm⁻⁵; p < 0.001 versus preoperative; p < 0.025 versus postoperative). Concomitantly, cardiac index was significantly increased compared with preoperative values (preoperative: 2.0 ± 0.7 L · min⁻¹ · m⁻²; follow-up: 2.9 ± 0.5 L · min⁻¹ · m⁻²; p < 0.001). Significant reductions of right ventricular dimensions and recovery of right ventricular function could be demonstrated radiologically and echocardiographically. In 3 patients (preoperative NYHA class IV, NYHA class III at follow-up) with proven coagulation abnormalities, pulmonary vascular resistance was moderately increased at follow-up compared with postoperative measurements.

Conclusions

In patients with chronic thromboembolic pulmonary hypertension, a persistent decrease of pulmonary vascular resistance and improvement of right ventricular function and NYHA functional status can be achieved by pulmonary thromboendarterectomy.

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Cited by (128)

Right ventricular adaptation to pulmonary pressure load in patients with chronic thromboembolic pulmonary hypertension before and after successful pulmonary endarterectomy - a cardiovascular magnetic resonance study
2014, Journal of Cardiovascular Magnetic Resonance
The aim of the study was to characterize RV adaptation to varying loading conditions in patients with chronic thromboembolic hypertension (CTEPH) before and after pulmonary endarterectomy (PEA). Nearly 4% of patients with pulmonary embolism develop CTEPH. PEA offers a cure with excellent outcome. By use of cardiovascular magnetic resonance (CMR) combined with hemodynamic measurements pulmonary arterial elastance (E_{a-pulm_i}), end-systolic right ventricular elastance (E_{es-RV_i}) and ventriculo-arterial coupling (E_{a-pulm_i}/E_{es-RV_i}) can be studied before and after PEA.
Sixty-five patients (mean age 41 ± 12 years, 28 female) underwent CMR pre- and post-PEA. Ejection fraction (EF), end-diastolic (EDV_i), end-systolic (ESV_i), and stroke (SV_i) volumes were indexed for body surface area. E_{a-pulm_i} was calculated as pulmonary artery mean pressure (mPAP)/SV_i, and E_{es-RV_i} as mPAP/ESV_i.
mPAP decreased from 47 ± 12 to 25 ± 9 mmHg, p =0.0001. E_{a-pulm_i} was increased before PEA and normalized afterwards (2.8 ± 2.1 vs. 0.85 ± 0.4 mmHg/ml/m², p =0.0001). E_{es-RV_i} was depressed before and after PEA (0.72 ± 0.27 vs. 0.66 ± 0.3 mmHg/ml/m², p =0.13). EF improved from 25 ± 12% to 46 ± 10%, p =0.0001, because ventriculo-arterial coupling was restored (4.2 ± 3 vs. 1.4 ± 0.6, p =0.0001). EDV_i and ESVi mproved significantly (EDV_i 92 ± 32 to 72 ± 23 ml, p =0.0001; ESV_i 69 ± 31 to 41 ± 18 ml, p =0.0001).
RV function is largely determined by afterload and returns to normal once afterload is normalized. This is paralleled by a significant improvement of CMR indices of right ventricular remodelling.
Progressive right ventricular dysfunction in patients with pulmonary arterial hypertension responding to therapy
2011, Journal of the American College of Cardiology
The purpose of this study was to examine the relationship between changes in pulmonary vascular resistance (PVR) and right ventricular ejection fraction (RVEF) and survival in patients with pulmonary arterial hypertension (PAH) under PAH-targeted therapies.
Despite the fact that medical therapies reduce PVR, the prognosis of patients with PAH is still poor. The primary cause of death is right ventricular (RV) failure. One possible explanation for this apparent paradox is the fact that a reduction in PVR is not automatically followed by an improvement in RV function.
A cohort of 110 patients with incident PAH underwent baseline right heart catheterization, cardiac magnetic resonance imaging, and 6-min walk testing. These measurements were repeated in 76 patients after 12 months of therapy.
Two patients underwent lung transplantation, 13 patients died during the first year, and 17 patients died in the subsequent follow-up of 47 months. Baseline RVEF (hazard ratio [HR]: 0.938; p = 0.001) and PVR (HR: 1.001; p = 0.031) were predictors of mortality. During the first 12 months, changes in PVR were moderately correlated with changes in RVEF (R = 0.330; p = 0.005). Changes in RVEF (HR: 0.929; p = 0.014) were associated with survival, but changes in PVR (HR: 1.000; p = 0.820) were not. In 68% of patients, PVR decreased after medical therapy. Twenty-five percent of those patients with decreased PVR showed a deterioration of RV function and had a poor prognosis.
After PAH-targeted therapy, RV function can deteriorate despite a reduction in PVR. Loss of RV function is associated with a poor outcome, irrespective of any changes in PVR.
Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: Results from an international prospective registry
2011, Journal of Thoracic and Cardiovascular Surgery
Pulmonary endarterectomy is a curative surgical treatment option for the majority of patients with chronic thromboembolic pulmonary hypertension. The current surgical management and postoperative outcome of patients enrolled in an international registry on chronic thromboembolic pulmonary hypertension were investigated.
The registry included newly diagnosed (≤6 months) consecutive patients with chronic thromboembolic pulmonary hypertension from February 2007 to January 2009.
A total of 679 patients were registered from 1 Canadian and 26 European centers, of whom 386 (56.8%) 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%) or bleeding (10.2%) complications, pulmonary reperfusion 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 predicted in-hospital and 1-year mortality. In patients evaluated within 1 year after surgery, the median pulmonary vascular resistance had decreased from 698 to 235 dyn.s.cm⁻⁵ (95% confidence limit, 640–874 and 211–255, respectively, n = 70) and the median 6-minute walk distance had increased from 362 to 459 m (95% confidence limit, 340–399 and 440–473, respectively, n = 168). New York Heart Association functional class improved with most patients progressing from class III/IV to class I/II.
Pulmonary endarterectomy is associated with a low in-hospital mortality rate and improvements in hemodynamics and exercise capacity.
Right ventricular load at exercise is a cause of persistent exercise limitation in patients with normal resting pulmonary vascular resistance after pulmonary endarterectomy
2011, Chest
Pulmonary endarterectomy (PEA) provides a potential cure for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, successfully operated patients can continue to suffer from a limitation of exercise capacity, despite normalization of pulmonary vascular resistance (PVR). The purpose of the present study was to explore the cardiopulmonary exercise test (CPET) profile and the pulmonary hemodynamic response to exercise in these patients.
Thirteen successfully operated patients with CTEPH and persistent dyspnea and control subjects underwent a CPET and a right-sided heart catheterization at rest and during exercise.
The CPET profile of the patients was characterized by mild hyperventilation and decreased peak oxygen uptake (
o₂). While there were no differences in resting hemodynamics between patients and control subjects, PVR was higher in the patients after 10 min of exercise (111 ± 46 dynes/s/cm⁵ vs 71 ± 42 dynes/s/cm⁵, P = .04), and pulmonary arterial compliance (Ca) was lower (5.5 ± 2.3 mL/mm Hg vs 8.1 ± 3.5 mL/mm Hg, P = .048). Ca under exercise correlated with peak
o₂ in the patients (R² = 0.825, P = .022).
After successful PEA, patients with persistent exertional dyspnea display an abnormal pulmonary hemodynamic response to exercise, characterized by increased PVR and decreased Ca. Decreased Ca under exercise is a strong predictor of limited exercise capacity in these patients.
Outcomes after pulmonary thromboendarterectomy
2010, Canadian Journal of Cardiology
Pulmonary thromboendarterectomy remains the procedure of choice for appropriate cases of chronic thromboembolic pulmonary hypertension. The acceptance of this strategy is based on comparisons of long-term survival between pertinent natural history studies of nonoperative treatment with that after the development of this surgery. A randomized controlled trial would never be deemed ethically appropriate or feasible at this time due to the tremendous success of surgery in afflicted patients. Aside from the survival advantage, surgery also results in a significant improvement in several quality-of-life factors such as physical, social, energy and general health, and a significant decrease in the need for supplemental oxygen, with many patients returning to work. The degree of improvement may be predicted by preoperative vasoresponsiveness at right heart catheterization as well as measures of upstream resistance. Postoperative elevated pulmonary pressures and resistance are the best predictors of a poor outcome, with the most common cause of death related to persistent pulmonary hypertension. In general, high-volume centres can achieve perioperative mortality rates of 4% to 10%, with a significant predicted improvement in all measures of cardiopulmonary hemodynamics and symptomatology.
La thromboendartériectomie pulmonaire demeure l’intervention de choix pour traiter les cas pertinents d’hypertension pulmonaire thromboembolique chronique. L’acceptation de cette stratégie se fonde sur les comparaisons de la survie à long terme entre les études pertinentes de l’évolution naturelle de traitement non opératoire et celles menées après la mise au point de cette opération. Un essai aléatoire et contrôlé ne serait jamais perçu comme pertinent ou faisable sur le plan éthique, en raison de l’énorme succès de l’opération chez les patients atteints. En plus des avantages pour la survie, l’opération procure également une amélioration marquée de plusieurs facteurs liés à la qualité de vie, tels que la santé physique, sociale, énergique et générale, et une diminution considérable des besoins en oxygène d’appoint, de nombreux patients étant en mesure de reprendre le travail. Le degré d’amélioration peut être prévu par la vasoréactivité préopératoire lors du cathétérisme du coeur droit et par les mesures de résistances en amont. Les tensions pulmonaires élevées après l’opération et la résistance sont les meilleurs prédicteurs d’une mauvaise issue, la cause de décès la plus courante étant une hypertension pulmonaire persistante. En général, les centres à fort débit peuvent parvenir à un taux de décès de 4% à 10%, ainsi qu’à une importante amélioration prévue de toutes les mesures d’hémodynamique et de symptomatologie cardiopulmonaires.
Pulmonary Endarterectomy Improves Dyspnea by the Relief of Dead Space Ventilation
2010, Annals of Thoracic Surgery
In chronic thromboembolic pulmonary hypertension (CTEPH), dyspnea is considered to be related to increased dead space ventilation caused by vascular obstruction. Pulmonary endarterectomy releases the thromboembolic obstruction, thereby improving regional pulmonary blood flow. We hypothesized that pulmonary endarterectomy reduces dead space ventilation and that this reduction contributes to attenuation of dyspnea symptoms.
In this follow-up study we assessed dead space ventilation, hemodynamic severity of disease, and symptomatic dyspnea in 54 consecutive CTEPH patients, before and 1 year after pulmonary endarterectomy. Dead space ventilation was calculated using the Bohr-Enghoff equation. Dyspnea was assessed by Borg scores and the New York Heart Association functional classification.
Preoperatively, dead space ventilation was increased (0.40 ± 0.07) and correlated with severity of disease (mean pulmonary artery pressure: r = 0.49, p < 0.001; total pulmonary resistance: r = 0.53, p < 0.001), and resting (r = 0.35, p < 0.05) and post-exercise Borg dyspnea scores (r = 0.44, p < 0.01). Postoperatively, dead space ventilation (0.33 ± 0.08, p < 0.001) and dyspnea symptoms decreased significantly. Changes in symptomatic dyspnea were independently associated with changes in pulmonary hemodynamics and absolute dead space.
Dead space ventilation in CTEPH is increased and correlates significantly with hemodynamic severity of disease and dyspnea symptoms. Pulmonary endarterectomy decreases dead space ventilation. The induced change in dead space upon surgical removal of chronic thromboembolism contributes to the postoperative recovery of symptomatic dyspnea.

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Original article: CardiovascularMid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

Background

Methods

Results

Conclusions

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Ann Thorac Surg

Chest

Chronic major-vessel thromboembolic pulmonary hypertension

Circulation

Chronic thromboembolic hypertension—clinical picture and surgical treatment

Eur Respir J

Original article: Cardiovascular
Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension