Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review of the Most Updated Literature

Abstract

Pulmonary endarterectomy (PEA) is the treatment of choice in case of chronic thromboembolic pulmonary hypertension (CTEPH). PEA is performed by an increasing number of surgeons; however, the reported outcomes are limited to a few registries or to individual centers’ experiences. This systematic review focuses on pre-operative evaluation, intra-operative procedure and post-operative results in patients submitted to PEA for CTEPH. The literature included was searched using a formal strategy, combining the terms “pulmonary endarterectomy” AND “chronic pulmonary hypertension” and focusing on studies published in the last 5 years (2017–2022) to give a comprehensive overview on the most updated literature. The selection of the adequate surgical candidate is a crucial point, and the decision should always be performed by expert multidisciplinary teams composed of surgeons, pulmonologists and radiologists. In all the included studies, the surgical procedure was performed through a median sternotomy with intermittent deep hypothermic circulatory arrest under cardiopulmonary bypass. In case of residual pulmonary hypertension, alternative combined treatments should be considered (balloon angioplasty and/or medical therapy until lung transplantation in highly selected cases). Short- and long-term outcomes, although not homogenous across the different studies, are acceptable in highly experienced CTEPH centers.

Notch ratio in pulmonary flow predicts long-term survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

“…TAPSE although the mean PVR (646 ± 454 dyn.s.cm −5 ) was not severely increased in our study. In a recent systematic review, the reported values of pre-PEA PVR ranged between 552 and 1536 dyn.s.cm −5 [24]. Several studies have shown that high pre-operative PVR values are associated with an increased mortality, with a 3 times higher in-hospital mortality in patients with pre-operative PVR > 1200 dyn.s.cm −5 [25,26].…”

Evaluation of total intravenous anesthesia with remimazolam in general anesthesia for pulmonary endarterectomy of chronic thromboembolic pulmonary hypertension: a case report

“…Higher levels of PVR and PAP can worsen the outcome of PEA [ 7 ], and it is critical to minimize the increases in PAP and PVR. Anesthetic management is also required to ensure that the right heart is not stressed.…”

Riociguat as bridging therapy to pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension: a retrospective cohort study

“…The use of PH targeted medications as a bridging therapy before PEA to optimize hemodynamics may positively impact perioperative outcomes. However, controversy exists regarding the utilization of targeted therapies before PEA ( 8 ). Pilot studies with bosentan or prostacyclin demonstrated improved pre-PEA hemodynamics but no significant difference post-PEA compared to controls ( 9 - 11 ).…”