Outcome after surgical treatment of chronic thromboembolic pulmonary hypertension: dealing with different patient subsets. A single-centre experience

Abstract

Objectives: Pulmonary endarterectomy (PEA) is the only curative treatment for patients suffering from chronic thromboembolic pulmonary hypertension (CTEPH). In patients with a pulmonary vascular resistance (PVR) higher than 1000 dynes s cm^-5, this procedure is linked with an increased perioperative risk. We compare the outcomes of patients with moderate to severe versus extremely elevated PVR.

Methods: Between 1992 and 2013, 214 patients underwent PEA for CTEPH at our institution. All patient data were entered in a prospective database. We performed a retrospective analysis of our total patient collective and of subgroups defined by: PVR ≤ 800, PVR > 800 < 1200 and PVR ≥ 1200 dynes s cm^-5, to assess the therapeutic success regarding pulmonary pressure reduction, functional outcome and risk factors for perioperative mortality.

Results: There was a significant reduction in mean pulmonary pressure (from 51 to 33 mmHg), PVR (860 to 337 dynes s cm^-5) and an increase in cardiac index (CI, 2.3 to 2.8 l/min/m²) in the whole group and in each subgroup. At 1-year follow-up, 91.2% of patients were alive and haemodynamic improvements were sustained in the majority of patients. Age, a PVR of higher than 800 dynes, NYHA functional class IV and a CI lower than 2.2 l/min/m² were significant predictors of in-hospital mortality. The median duration of surgery was 360 min, cardiopulmonary bypass 230 min, aortic cross-clamp time 150 min and circulatory arrest 34 min. In total, there were 14 in-hospital deaths (6.5%) mainly due to right heart failure (n = 7) and multiorgan failure (n = 3). Bleeding, stroke, sepsis and pneumonia led to death in 1 patient each. Mortality was significantly higher in the two groups with PVR > 800, but absolute pressure reduction was also higher in these groups. The 1-year survival rate was 91.2%.

Conclusions: Despite the increased perioperative risk and mortality, PEA should not be denied to patients with extremely elevated PVR but clear indication for surgery. Keeping increased perioperative risk and mortality in mind, significant pressure reduction and improved functional outcome can be achieved in the majority of these patients.

Keywords: Chronic thromboembolic pulmonary hypertension; Pulmonary endarterectomy; Pulmonary hypertension.