Elsevier

The Annals of Thoracic Surgery

Volume 68, Issue 5, November 1999, Pages 1770-1776
The Annals of Thoracic Surgery

Original Articles
Reoperative pulmonary thromboendarterectomy

Presented at the Thirty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25–27, 1999.
https://doi.org/10.1016/S0003-4975(99)01043-7Get rights and content

Abstract

Background. Recurrent symptomatic pulmonary hypertension is uncommon after primary pulmonary thromboendarterectomy (PTE). We reviewed our experience with patients undergoing repeat PTE to determine the risk factors for recurrent disease, and the selection criteria, relative risks, and functional outcomes of reoperative PTE.

Methods. Since 1990, 13 of 870 (1.5%) patients underwent reoperative PTE at our institution. These 7 men and 6 women (mean age 38.6 years) were contrasted with the most recent 225 patients (111 men, 114 women, mean age 52.7 years) who underwent primary PTE for whom complete hemodynamic data are available. The preoperative evaluation of all patients was similar. Pulmonary hemodynamic data and outcome measures were compared between groups.

Results. Of 13 reoperated patients: 69% (9/13) had their primary operation at another institution, 54% (7/13) initially underwent unilateral PTE, 38% (5/13) had identifiable coagulation disorders, 38% (5/13) had ineffective caval filtration, 31% (4/13) had suboptimal anticoagulation management, and 31% (4/13) had complete unilateral pulmonary artery obstruction. The mean interval to reoperation was 5.2 years (range 0.7 to 10.9 years). All control patients underwent bilateral PTE using hypothermic circulatory arrest. Operative mortality was 7.7% (1/13) with reoperation vs 8.4% (19/225) in controls. No difference (p = NS) was observed between groups in the preoperative pulmonary artery pressure (PAP) or pulmonary vascular resistance; however, the control group had a significantly (p < 0.05) greater reduction in the postoperative PAP (46/19, mean 28 mm Hg vs 59/23, mean 35 mm Hg) and PVR (271 ± 172 vs 399 ± 154 dynes/s/cm−5) compared with the redo group. No substantial difference in morbidity or functional outcomes was observed between groups.

Conclusions. Reoperative PTE can be performed with a perioperative risk comparable with primary PTE, although the improvement in pulmonary hemodynamics is not as favorable. Bilateral primary operation, effective caval filtration, and vigilant anticoagulant management would prevent the need for most reoperative PTEs.

Section snippets

Patients and methods

Between November 1989 and December 1998, 870 consecutive PTEs for chronic thromboembolic pulmonary hypertension were performed by two surgeons at the University of California, San Diego Medical Center. During this period, 13 patients (1.5%) underwent repeat PTE. Reoperated patients were contrasted with a consecutive cohort of 225 control patients who underwent primary PTE between March 1996 and December 1997, and for whom complete hemodynamic data were available.

Our routine preoperative

Patient demographics

Preoperative and postoperative data for redo and primary patients are displayed in Table 1, Table 2. Seven reoperated patients were men and 6 were women. This distribution did not differ from the control group (111 men and 114 women). Reoperated patients were younger (39 ± 15 years, range 20 to 69 years) than the reference population (53 ± 15 years, range 16 to 85 years) (p < 0.01).

Nine of the 13 (69%) redo patients received their initial PTE operation elsewhere. This operation was unilateral

Comment

Acute pulmonary thromboembolism is a more common condition than is generally appreciated, and in many cases, is asymptomatic until end-stage debilitating pulmonary hypertension develops. In the majority of patients, spontaneous resolution of acute pulmonary embolism is the rule. However, a small but uncertain percentage develop chronic thromboembolic pulmonary hypertension for which medical therapy is ineffective 3, 4, leaving surgical intervention the only definitive option 7, 8, 9, 16, 17.

The

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