Original article
Adult cardiac
Pulmonary Endarterectomy: Recent Changes in a Single Institution's Experience of More Than 2,700 Patients

Presented at the Forty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 31–Feb 2, 2011.
https://doi.org/10.1016/j.athoracsur.2012.04.004Get rights and content

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is a known sequela of acute pulmonary embolic disease and yet remains underdiagnosed. Although nonsurgical options for patients with CTEPH have become increasingly available, including pulmonary artery hypertensive medical therapy, surgical endarterectomy provides the most appropriate intervention as a potential cure for this debilitating disorder. This article summarizes the most recent outcomes of pulmonary endarterectomy at a single institution over the past 12 years, with emphasis on the surgical approach to segmental-level chronic thromboembolic disease.

Methods

More than 2,700 pulmonary endarterectomy operations have been performed at the University of California, San Diego Medical Center. Because of recent changes in the patient population and in surgical results, 1,500 patients with symptomatic chronic thromboembolic disease who underwent pulmonary endarterectomy between March 1999 and December 2010 were analyzed. The outcomes for the more recent 500 patients, compared with the previous 1,000 were studied.

Results

In-hospital mortality for the cohort of 1,000 patients (group 1) was 5.2% compared with 2.2% for the last 500 operations (group 2) (p < 0.01). There was no mortality in the last 260 consecutive patients undergoing isolated pulmonary endarterectomy. More patients presented with segmental type III disease in the more recent 500 patients (21.4% versus 13.1%; p < 0.001). Between the 2 patient groups, there was a comparable decline in pulmonary vascular resistance (PVR) (group 1: 861.2 ± 446.2 to 94.8 ± 204.2 dynes/sec/cm−5; group 2: 719.0 ± 383.2 to 253.4 ± 148.6 dynes/sec/cm−5) and mean pulmonary artery (PA) pressures (group 1: 46.1 ± 11.4 to 28.7 ± 10.1 mm Hg; group 2: 45.5 ± 11.6 to 26.0 ± 8.4 mm Hg) after endarterectomy.

Conclusions

Despite a patient population with more distal disease, results continue to improve. Pulmonary endarterectomy for patients with CTEPH results in significant pulmonary hemodynamic improvement, with favorable outcomes achievable even in patients with distal segmental-level chronic thromboembolic disease.

Section snippets

Selection

The purpose of this study was to determine whether our experience with sicker patients with more distal disease now being referred to our center adversely affected outcome. A retrospective review of our database identified 1,500 patients with CTEPH who underwent pulmonary endarterectomy at UCSD between March 1999 and December 2010. For the purposes of this study, informed consent was waived and data collected in accordance with the standards set by UCSD's Institutional Review Board. Patients

Results

All patients underwent bilateral pulmonary endarterectomy. The mean patient age was 51.6 years, with a range of 8 to 86 years. The preoperative characteristics of both patient groups are summarized in Table 1. Preoperative hemodynamic measurements revealed a trend toward a lower PVR in the most recent patient group. However there was a statistically significant increase in the number of group 2 patients requiring intravenous inotropes before operation, and although not achieving statistical

Comment

Over the past decade, a wide variety of new medical therapies have been developed for the treatment of pulmonary hypertension. These include prostacyclin analogues, phosphodiesterase inhibitors, and endothelium receptor antagonists [3, 4, 5]. There has been an increased use of these medical therapies in patients with CTEPH. As a consequence, we are seeing a delay in patient referrals, even in patients who have obvious operable disease. In 2010, 45% of patients with operable CTEPH referred for

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