Time trends of pulmonary endarterectomy in patients with chronic thromboembolic pulmonary hypertension

Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered as a rare but severe complication after acute pulmonary embolism (PE) and is potentially curable by pulmonary endarterectomy (PEA). We aimed to evaluate, over an 11-year period, time trends of in-hospital outcomes of PEA in CTEPH patients and to investigate predictors of the in-hospital course. We analyzed data on the characteristics, comorbidities, treatments and in-hospital outcomes for all CTEPH patients treated with PEA in the German nationwide inpatient sample between 2006 and 2016. Overall, 1,398 inpatients were included. Annual number of PEA increased from 67 in 2006 to 194 in 2016 (P<0.001), in parallel with a significant decrease of in-hospital mortality (10.9% in 2008 to 1.5% in 2016; P<0.001). Patients’ characteristics shifted slightly towards older age and higher prevalence of chronic renal insufficiency and obesity over time, whereas duration of hospital stay decreased over time. Independent predictors of in-hospital mortality were age (OR 1.03 [95%CI 1.01-1.05]; P=0.001), right heart failure (2.55 [1.37-4.76]; P=0.003), in-hospital complications such as ischemic stroke (6.87 [1.06-44.70]; P=0.044) and bleeding events like hemopneumothorax (24.93 [6.18-100.57]; P<0.001). Annual PEA volumes per center below 10 annual procedures were associated with higher rates of adverse in-hospital outcomes. Annual numbers of CTEPH patients treated with PEA increased markedly in Germany between 2006 and 2016, in parallel with a decrease of in-hospital mortality. Our findings suggest that perioperative management of PEA, institutional experience and patient-selection are crucial and have improved over time.

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review

“…Mediastinitis and deep sternal wound infection rates, associated with deep hypothermic arrest in other forms of cardiac surgery, were reported in up to 6% of patients in international registries, but were not reported in series from individual centers (16). Whilst it is a positive step that three significant national registries published results in 2021, only one of these published morbidity data and pre-and post-operative haemodynamic outcomes (17,38,40). It will become increasingly important that these large-volume, well-supported prospective registries continue to collect and report data for CTEPH and patients undergoing PTE.…”

“…It was required in 0% to 56.3% of patients (median 5.5%), with indications including right ventricular support, failure to wean from cardiopulmonary bypass and failure to oxygenate due to reperfusion pulmonary oedema (9,(32)(33)(34). In the two largest reporting series it was required in 5.1 and 5.5% of patients (9,38). Survival for patients requiring ECMO ranged from 25% to 57% (25,35,72).…”

“…This is greatly dependent on the hospitals' bed flow and ward capacity/ceilings of care. Total post-operative hospital length of stay ranged from ten to forty-five days, with a median of fifteen days (Table S2) (9,15,22,23,25,32,33,(36)(37)(38)(39)42,44,(48)(49)(50)53,(55)(56)(57)62,65,68,69).…”

Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center

“…The different patterns of CTEPH between both sexes could have influenced the received treatment, but many other factors could also be related. In recently published work by Hobohm et al [ 30 ], the number of PEA also increased in Germany during the last 11 years, and in-hospital death decreased in parallel, suggesting that patient selection and institutional experience could be important determinants of outcomes. Regarding BPA, a contemporary experience of a Japanese referral center during the 2011–2019 period also showed that many more women were treated only with pulmonary vasodilators (66.7 of the total number of patients treated exclusively with medical therapy were women), and a higher number of women were treated with BPA (84.4% of the number of patients who only received BPA) when compared with the proportion of patients treated with PEA (56.2% of them women) or with the combination of PEA and BPA (64.0% of them women) [ 31 ].…”

Circulating miR-let7a levels predict future diagnosis of chronic thromboembolic pulmonary hypertension

“…Pulmonary embolism (PE) is the third most common cardiovascular disease with an annual incidence of 39–115 per 100,000 person-years and is associated with serious short- and long-term complications including recurrence, chronic thromboembolic pulmonary hypertension (CTEPH) and death 1 , 2 . CTEPH is a rare disease, but is associated with high mortality rates and poor prognosis if left untreated 3 , 4 . In recent years, microRNAs (miRNAs) emerged as novel biomarkers and distinct patterns were found to exhibit diagnostic and prognostic value for different disease settings, including various cardiovascular diseases 5 , 6 .…”