Pulmonary endarterectomy in the management of chronic thromboembolic pulmonary hypertension

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is a type of pulmonary hypertension, resulting from fibrotic transformation of pulmonary artery clots causing chronic obstruction in macroscopic pulmonary arteries and associated vascular remodelling in the microvasculature.Pulmonary endarterectomy (PEA) offers the best chance of symptomatic and prognostic improvement in eligible patients; in expert centres, it has excellent results. Current in-hospital mortality rates are <5% and survival is >90% at 1 year and >70% at 10 years. However, PEA, is a complex procedure and relies on a multidisciplinary CTEPH team led by an experienced surgeon to decide on an individual's operability, which is determined primarily by lesion location and the haemodynamic parameters. Therefore, treatment of patients with CTEPH depends largely on subjective judgements of eligibility for surgery by the CTEPH team.Other controversies discussed in this article include eligibility for PEA balloon pulmonary angioplasty, the new treatment algorithm in the European Society of Cardiology/European Respiratory Society guidelines and the definition of an "expert centre" for the management of this condition.

Balloon pulmonary angioplasty vs riociguat in patients with inoperable chronic thromboembolic pulmonary hypertension: A systematic review and meta‐analysis

“…The possible reasons may be as follows: Firstly, the identification of the location and characters of thromboembolic lesions is important in patient management because it determines the optimal therapy choice. Lesions in the proximal main, lobar and segmental arteriesand, in some cases, distally located midsegmental and subsegmental branches can be surgically removed by pulmonary endarterectomy. At experienced centers, segmental and subsegmental resection can be performed with excellent effects.…”

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

“…Pulmonary endarterectomy (PEA) is the gold-standard treatment. PEA is a potentially curative intervention, which in expert centres carries an in-hospital mortality rate <5% and confers haemodynamic and functional improvement with good long-term survival [10,11]. However, <60% of patients with CTEPH can undergo PEA, and pulmonary hypertension persists or recurs after the procedure in 17-31% of patients [12,13].…”

After the Dawn ― Balloon Pulmonary Angioplasty for Patients With Chronic Thromboembolic Pulmonary Hypertension ―

“…The reported cumulative incidence of CTEPH is 0.1-9.1% within the first 2 years after a symptomatic event of pulmonary embolism. 1,2 Pulmonary endarterectomy (PEA) is the gold standard therapy for CTEPH, 1,3, 4 and recently reported outcomes of PEA performed at expert centers have been excellent. 4-6 However, the surgical technique of PEA requires proficiency and thus the procedure is performed at limited numbers of institutions.…”

“…4-6 However, the surgical technique of PEA requires proficiency and thus the procedure is performed at limited numbers of institutions. [4][5][6][7][8] Patients deemed suitable for PEA are those in WHO functional class III or IV and with lesions mainly located in the lobar and segmental pulmonary arteries. Patients with lesions in the distal arteries and/or elderly patients and those with comorbidities have been considered to have an unfavorable risk/benefit ratio and are often deemed inoperable.…”