Long‐term outcome prediction for chronic thromboembolic pulmonary hypertension after pulmonary endarterectomy

Abstract

Background: The definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA), which has good longterm outcomes. However, after surgery, a quarter of the patients still have residual pulmonary hypertension (RPH). In pulmonary hemodynamics, there are no unified criteria for RPH, even though the level may affect long-term survival.Methods: Between March 1997 and December 2021, 253 CTEPH patients were treated at our center with PEA. Patients were evaluated retrospectively and classified into early (1997)(1998)(1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010)(2011)(2012)(2013)(2014) and late (2015-2021) groups. The clinical characteristics and perioperative outcomes of the two groups were compared, and risk factor analysis for RPH and long-term survival for all cases was performed.Results: There was no statistically significant difference in demographics between the two groups. However, the Early Group had a significantly higher rate of perioperative death (9.8% vs. 1.2%, p = .001), RPH (48.8% vs. 14.0%, p < .001), and reperfusion pulmonary edema (18.3% vs. 2.9%, p < .001). The median follow-up time was 66.0 months, and overall survival rates at 5, 10, 15, and 18 years after PEA were 91.2%, 83.9%, 64.5%, and 46.0%, respectively. Age and postoperative systolic pulmonary artery pressure (sPAP) were independently related to long-term outcomes in the multivariate Cox analyses. Patients with postoperative sPAP less than 46 mm Hg had a higher chance of survival. Conclusions: PEA improved CTEPH hemodynamics immediately and had a positive effect on long-term survival. Patients with postoperative sPAP ≥ 46 mm Hg indicate clinically significant RPH and have a lower long-term survival rate.

Pulmonary endarterectomy in patients with occlusive isolated pulmonary vasculitis

“…According to reports from the University of California-San Diego Medical Center where the PEA technique was pioneered and developed, perioperative mortality decreases from 20% in the early stages to 2%, with 5- and 10 year survival rates of 82% and 75%, respectively, which were significantly improved compared with those who did not receive PEA [ 8 , 11 ]. Based on the most recent similar results from our center, which have become better over time, the perioperative death rate was 1.2% (2/171) in 2015, with a 10-year survival rate of 83.9% [ 10 ]. Similar to the prior CTEPH group, the majority of the patients in the current cohort did not have postoperative complications, including reperfusion pulmonary edema, pulmonary bleeding, delirium, or lung infection, regardless of whether an additional patch expansion of PA was performed.…”

“…Similar to the prior CTEPH group, the majority of the patients in the current cohort did not have postoperative complications, including reperfusion pulmonary edema, pulmonary bleeding, delirium, or lung infection, regardless of whether an additional patch expansion of PA was performed. These advancements might be attributed to the accumulated surgical expertise gained during the learning curve, bloodless vision with deep hypothermic circulatory arrest, enhanced perfusion strategy, and integrated management in the cardiac critical care unit [ 10 , 12 ].…”

“…As the peripheral portion of the arterial tree accounted for more than 80% of the pulmonary arterial compliance [ 13 ] and determined the normalization of pulmonary vascular resistance [ 14 ] following successful PEA, PEA limited to the major left PA was insufficient for this patient. In our experience, arteries in the IPV were more likely to be transmurally implicated and to exhibit circumferential artery wall fusion and thickening, which correlates to the widespread lymphocytic infiltration, whereas in CTEPH, inner layer alteration was predominantly observed [ 10 ]. The PEA in IPV has occasionally been technically challenging due to this anatomical difference, particularly when surgeons attempt to reach the lobar segmental PA and separate the intima.…”

“…Similar to the regular CTEPH operations carried out by the University of California-San Diego Medical Center and as previously described [ 7 – 10 ], all PEAs were completed by the same senior, experienced surgeon (S Liu), who has performed more than 30 PEAs annually in the past 5 years. In brief, following aortic and venous cannulations, cardiopulmonary bypass was initiated, and cooling commenced.…”

Association of Prolonged Nocturnal Hypoxemia with Clinical Worsening in Patients with Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Endarterectomy

“…A patient is deemed operable when adequate surgically accessible thromboembolic material is present, and a proportionate PVR indicates the absence of extensive distal disease. Notably, highly specialized centers have shown optimal success rates [ 3 ], and our institution recorded an overall survival rate of 91.2% and 83.9% at 5 and 10 years, respectively, for patients with CTEPH who underwent PEA [ 29 ]. Our study revealed no patients that died during hospitalization after PEA.…”