C hronic thromboembolic pulmonary hypertension (CTEPH) is a complication of acute pulmonary emboli with uncertain prevalence, ranging from 0.57% to 9.1%. 1The diagnosis is strongly associated with a history of acute venous thromboembolism.2 CTEPH results from incomplete Editorial, see p 1731 Clinical Perspective on p 1771resolution of pulmonary emboli that become organized into vessel walls and cause different degrees of obstruction to Background-Chronic thromboembolic pulmonary hypertension results from incomplete resolution of pulmonary emboli.Pulmonary endarterectomy (PEA) is potentially curative, but residual pulmonary hypertension following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual pulmonary hypertension post-PEA. Methods and Results-Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require pulmonary vasodilator therapy. Cox regressions were used for survival (time-toevent) analyses. Overall survival was 86%, 84%, 79%, and 72% at 1, 3, 5, and 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s -1 ·cm -5 at reassessment correlated with worse long-term survival. Conclusions-Our data confirm excellent long-term survival and maintenance of good functional status post-PEA.Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery. 4 It is recognized that there is a steep surgical and institutional learning curve at the start of a PEA program, but, in experienced centers, the operative mortality rate is <5%.5-7 A number of reports have confirmed improved short-term outcome in terms of hemodynamics, right ventricular function, quality of life, functional status, and exercise capacity after surgery. [7][8][9][10][11][12][13][14][15][16][17][18] Fewer reports describe long-term outcome post-PEA, and those that have been published are mainly retrospective and either only had small numbers of patients [19][20][21][22][23][24][25][26] or limited information of factors correlated with long-term outco...

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Chronic thromboembolic disease is characterised by persistent pulmonary thromboembolic occlusions without pulmonary hypertension. Early surgical treatment with pulmonary endarterectomy may improve symptoms and prevent disease progression. We sought to assess the outcome of pulmonary endarterectomy in symptomatic patients with chronic thromboembolic disease.Patients with symptomatic chronic thromboembolic disease and a mean pulmonary artery pressure ,25 mmHg at baseline with right heart catheterisation and treated with pulmonary endarterectomy between January 2000 and July 2013 were identified. Patients were reassessed at 6 months and at 1 year following surgery.A total of 42 patients underwent surgery and the median length of stay in hospital was 11 days. There was no in-hospital mortality but complications occurred in 40% of patients. At 1 year, following surgery, 95% of the patients remained alive. There was a significant symptomatic improvement with 95% of patients in the New York Heart Association functional classes I or II at 6 months. There was a significant improvement in quality of life assessed by the Cambridge pulmonary hypertension outcome review questionnaire.In this carefully selected cohort of chronic thromboembolic disease patients, pulmonary endarterectomy resulted in significant improvement in symptoms and quality of life. Appropriate patient selection is paramount given the known surgical morbidity and mortality, and surgery should only be performed in expert centres. @ERSpublications Pulmonary endarterectomy improves symptoms and quality of life in patients with chronic thromboembolic disease http://ow.ly/AeECt

For patients undergoing pulmonary endarterectomy, survival after hospital discharge is excellent. Residual pulmonary hypertension significantly compromised symptom status and functional capacity but did not appear to adversely affect medium-term survival. The effect of targeted medical therapy in patients with residual pulmonary hypertension after pulmonary endarterectomy needs to be evaluated further.