Operative classification of thromboembolic disease determines outcome after pulmonary endarterectomy

Thistlethwaite, Patricia A.; Mo, Makato; Madani, Michael M.; Deutsch, Reena; Blanchard, Daniel G.; Kapelanski, David P.; Jamieson, Stuart W.

doi:10.1067/mtc.2002.127313

Cited by 258 publications

(209 citation statements)

References 24 publications

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“…In their study, Thistlethwaite and colleagues divided patients into 4 groups, according to intraoperative classification 30 : type 1, fresh thrombus in the main-lobar pulmonary arteries; type 2, intimal thickening and fibrosis proximal to segmental arteries; type 3, disease within distal segmental arteries only; type 4, distal arteriolar vasculopathy. In the present series, all patients with central type (CD score ≥2) had type 1 or 2, whereas of the patients with relatively peripheral type, 2 patients with a CD score of 0 were type 3, and 1 patient with a CD score of 1 was type 4.…”

Section: Discussionmentioning

confidence: 99%

Survival and Quality of Life for Patients With Peripheral Type Chronic Thromboembolic Pulmonary Hypertension

Yoshimi

Tanabe

Masuda

et al. 2008

Circ J

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hronic thromboembolic pulmonary hypertension (CTEPH) is a relatively rare disease. Its natural history and etiology remain unclear. [1][2][3][4][5] There have been a number of reports that pulmonary thromboendarterectomy (PTE) is an effective modality for treatment in selected patients with CTEPH. [1][2][3][6][7][8][9][10][11] However, the hemodynamic benefit varies according to the location and extent of the thromboembolic occlusion, and Bergin and colleagues reported that the computed tomography (CT) angiographic extent of central disease (ie, CD score) is related to a low pulmonary vascular resistance (PVR) after surgery. 12 Our preliminary data also showed high operative mortality with CD scores of 0 (25%) and 1 (20%), compared with those with a CD score of ≥2 (7.7%), so we classified those patients with a CD score of ≤1 as having relatively peripheral type CTEPH. The cause of operative death was related to residual pulmonary hypertension as a result of failure to remove a distal obstruction. New guidelines have recommended a post-surgical estimated reduction in PVR of >50%. 10 The validity of PTE might be limited to central-type patients, especially in institutions in which the operation is performed infrequently.The prognosis of CTEPH in the medically treated group had been thought to be poor, 13-15 but Ono et al reported that oral beraprost sodium improved their survival. 16 Recently, there have been some reports about improved 6-min walk distance and pulmonary hemodynamics after epoprostenol, 17,18 sildenafil 19 and bosentan [20][21][22] in patients with CTEPH. These new drugs might improve vascular remodeling, and may offer improved survival in patients with relatively peripheral type CTEPH, in whom we predicted a poor reduction in PVR after surgery. We retrospectively tested the validity of PTE from the aspects of survival and quality of life (QOL) at long-term follow up in patients with relatively peripheral type CTEPH. Methods PatientsBetween April 1999 and March 2006, a total of 83 patients admitted consecutively to Chiba University Hospital were diagnosed as having CTEPH and evaluated for surgical indication. CTEPH was defined as having a mean pulmonary arterial pressure (PPA) of ≥25 mmHg with normal wedge pressure in patients who had dyspnea on exertion during a period of more than 6 months. In addition, lung

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Section: Discussionmentioning

confidence: 99%

Survival and Quality of Life for Patients With Peripheral Type Chronic Thromboembolic Pulmonary Hypertension

Yoshimi

Tanabe

Masuda

et al. 2008

Circ J

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“…Both had significant distal disease on pre-operative assessment. The remainder of the operable group were surgically classified at the time of operation (using the THISTLETHWAITE et al [9] classification) as predominantly type II/III disease and adjudged to have good technical clearance (table 1).…”

Section: Subjectsmentioning

confidence: 99%

Occlusion pressure analysis role in partitioning of pulmonary vascular resistance in CTEPH

Toshner¹,

Suntharalingam²,

Fesler³

et al. 2012

Eur Respir J

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Flow-directed pulmonary artery occlusion is posited to enable partitioning of vascular resistance into small and large vessels. As such it may have a role in assessment for pulmonary endarterectomy.To test if the occlusion technique distinguished small from large vessel disease we studied 59 subjects with chronic thromboembolic pulmonary hypertension (CTEPH), idiopathic pulmonary arterial hypertension (IPAH), and connective tissue disease (CTD)-associated PAH. At right heart catheterisation, occlusion pressures were recorded. With fitting of the pressure decay curve, pulmonary vascular resistance was partitioned into downstream (small vessels) and upstream (large vessels, Rup).47 patients completed the study; 14 operable CTEPH, 15 inoperable CTEPH, 13 idiopathic or CTD-PAH and five post-operative CTEPH. There was a significant difference in mean Rup in the proximal operable CTEPH group 87.3 (95% CI 84.1-90.5); inoperable CTEPH mean 75.8 (95% CI 66.76-84.73), p50.048; and IPAH/CTD, mean 77.1 (95% CI 71.86-82.33), p50.003. Receiver operating characteristic curves to distinguish operable from inoperable CTEPH demonstrated an area under the curve of 0.75, p50.0001. A cut-off of 79.3 gave 100% sensitivity (95% CI 73.5-100%) but 57.1% specificity (95% CI 28.9-82.3%). In a subgroup analysis of multiple lobar sampling there was demonstrable heterogeneity.Rup is significantly increased in operable proximal CTEPH compared with non-operable distal CTEPH and IPAH/CTD-PAH. Rup variability in patients with CTEPH and PAH is suggestive of pathophysiological heterogeneity.

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“…[4][5][6] In addition, a previous study showed that patients with a PVR greater than 1,100 dynes·sec −1 ·cm −5 and an mPAP greater than 50 mmHg had a poor outcome. 8) Jamieson et al also reported that 17 of 22 hospital deaths (77%) were related to residual pulmonary hypertension, and the mortality rate was 31% when the postoperative PVR was >500 dynes·sec ·cm −5 in case 2.…”

Section: Discussionmentioning

confidence: 99%

“…In particular, for patients with distal pulmonary artery disease, PEA is, technically, more difficult and, obviously, its outcome is much poorer than that of proximal disease. [4][5][6][7] In our previous study, we also reported that the mortality of proximal and distal disease after PEA was 3.9% and 13.5%, respectively. 7) In this report, we present two exceptionally difficult cases of severe CTEPH with proximal lesions who died from residual pulmonary hypertension after effective likelihood PEA.…”

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confidence: 99%

Surgical Outcome of Two Difficult Cases with Predominant Proximal Pulmonary Artery Lesions of Chronic Thromboembolic Pulmonary Hypertension

Murashita

Ogino

Matsuda

et al. 2011

Annals of Vascular Diseases

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Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is still challenging. The outcome of patients with proximal pulmonary artery disease is generally better than that of a distal lesion. However, we experienced poor results in two difficult cases having predominant proximal lesions even after effective PEA. Both of them had a long-time history of CTEPH and preoperative condition was critical. Although relatively large amount of thickened intima with massive thrombi were extracted from the proximal pulmonary arteries, they required postoperative percutaneous cardiopulmonary support due to residual pulmonary hypertension. Both of them finally died from pulmonary bleeding and adult respiratory distress syndrome.

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Operative classification of thromboembolic disease determines outcome after pulmonary endarterectomy

Cited by 258 publications

References 24 publications

Survival and Quality of Life for Patients With Peripheral Type Chronic Thromboembolic Pulmonary Hypertension

Survival and Quality of Life for Patients With Peripheral Type Chronic Thromboembolic Pulmonary Hypertension

Occlusion pressure analysis role in partitioning of pulmonary vascular resistance in CTEPH

Surgical Outcome of Two Difficult Cases with Predominant Proximal Pulmonary Artery Lesions of Chronic Thromboembolic Pulmonary Hypertension

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