Elsevier

The Annals of Thoracic Surgery

Volume 76, Issue 5, November 2003, Pages 1457-1464
The Annals of Thoracic Surgery

J. Maxwell Chamberlain Memorial paper: cardiovascular
Pulmonary endarterectomy: experience and lessons learned in 1,500 cases

Presented at the Thirty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2003.
https://doi.org/10.1016/S0003-4975(03)00828-2Get rights and content

Abstract

Background

The incidence of pulmonary hypertension resulting from chronic thrombotic occlusion of the pulmonary arteries is significantly underestimated. Although medical therapy for the condition is supportive only, surgical therapy is curative. Our pulmonary endarterectomy program was begun in 1970, and 188 patients were operated on in the subsequent 20 years. With the increased recognition of the disease and the success of operative therapy, however, more than 1,400 operations have been done since 1990 at our center.

Methods

The safety and efficacy of the operation was assessed with changes made through increased experience. We examined in detail the results of our last 500 consecutive patients.

Results

Median sternotomy, cardiopulmonary bypass, profound hypothermia, and circulatory arrest were found to be essential to the success of the operation. All occluding material could be removed at operation. We currently believe that there is no degree of embolic occlusion within the pulmonary vascular tree that is inaccessible and no degree of right ventricular impairment or any level of pulmonary vascular resistance that is inoperable. With shorter cardiac arrest periods and the use of a cooling jacket to the head, cerebral impairment has been eliminated. The pulmonary artery pressures and pulmonary vascular resistance in a recent cohort of 500 patients is examined. The mortality rate for the operation has been reduced steadily, and was 22 of the last 500 patients operated on (4.4%).

Conclusions

The operation is considered curative and therefore greatly superior to transplantation for this condition. Current techniques of operation make the procedure relatively safe.

Section snippets

Patient selection

The first pulmonary thromboendarterectomy operation at UCSD was done in 1970 [1], and 188 operations were carried out in the ensuing 20 years. The program has grown steadily since 1990, and 1,580 patients had been operated on by December 2002. Patients are referred nationally and internationally to this center, and the number of referrals increases yearly, indicating an increased awareness of the disease and the effectiveness of therapy rather than an increased incidence. The clinical

Results

There is undoubtedly a learning curve for the operation. The operative mortality rate was 17% for the first 200 patients in the beginning of the UCSD series (1970 to 1990). Changes were made in the operative technique in 1990 [3], and the perioperative mortality rate has since steadily declined, to 8.8% for the 500 individuals who had the operation between 1994 and 1998, and to 4.4% for the 500 patients operated on between 1998 and 2002.

The cohort of 500 consecutive patients was analyzed in

Unappreciated incidence

Pulmonary hypertension as a result of pulmonary embolism is an unappreciated but major cause of morbidity and mortality. Its incidence is difficult to calculate because of the uncertainty regarding the frequency of acute pulmonary embolism and the proportion of patients with acute pulmonary emboli in whom embolic residua fail to resolve. In 1975, Dalen and Alpert [5] calculated that pulmonary embolism resulted in 630,000 symptomatic episodes in the United States, making it about half as common

Acknowledgements

Cleonice Gordon and David Garcia were invaluable in data analysis. Reena Deutsch assisted in the statistical analysis. Reena Deutsch is funded by General Clinical Research Center grant National Institutes of Health M01 RR00827.

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