Pulmonary endarterectomy: the potentially curative treatment for patients with chronic thromboembolic pulmonary hypertension

Abstract

Pulmonary endarterectomy (PEA) is the treatment of choice to relieve pulmonary artery obstruction in patients with chronic thromboembolic pulmonary hypertension (CTEPH). It is a complex surgical procedure with a simple principle: removal of obstructive thromboembolic material from the pulmonary arteries in order to reduce pulmonary vascular resistance, relieve pulmonary hypertension (PH) and alleviate right ventricular dysfunction. In the majority of patients there is symptomatic and prognostic benefit. However, not all patients with CTEPH are suitable for treatment with PEA. Operability assessment is not always easy, being largely subjective and based on experience. It is therefore important that all patients are referred to an experienced CTEPH centre for careful evaluation of suitability for surgery. The most common reason for inoperability is distal vasculopathy accounting for a high proportion of the vascular resistance. Surgery requires cardiopulmonary bypass and periods of deep hypothermic circulatory arrest. Complications include reperfusion lung injury and persistent PH. However, with careful patient selection, surgical technique and post-operative management, PEA is a highly effective treatment with mortality rates <5% at experienced centres. Patients who are unsuitable for surgery may be candidates for medical therapy. @ERSpublications A review of pulmonary endarterectomy as a CTEPH treatment, including patient assessment, risks and outcomes http://ow.ly/L82F7

Chronic thromboembolic pulmonary hypertension - a diagnostic and therapeutic update

“…It is a surgically demanding technique and requires experience for the assessment of operability as well as technical skills for its performance. There are only a few centres worldwide with a case load > 1000 interventions and its delicate postoperative surveillance necessary to obtain a perioperative mortality < 5 % [15]. An expert centre is by defi nition one that performs at least 20 PEA operations per year with a mortality rate of < 10 %.…”

“…Most patients will have haemodynamic abnormalities at rest, but in selected cases, patients with markedly increased pulmonary vascular resistance upon exercise have shown to benefi t from surgical intervention [15]. It must be underscored that patients should be evaluated only by an expert team in PEA before operations may be withheld.…”

“…It must be underscored that patients should be evaluated only by an expert team in PEA before operations may be withheld. Temporal delay to evaluation of operability can result in a negative outcome, and medical bridging while postponing a specifi c assessment is not recommended [15].…”

“…Up to 30 % of the patients may present with postoperative residual/persistent pulmonary hypertension, which negatively infl uences prognostic outcomes. Those patients may be candidates for medical treatment [15].…”

Molecular mechanisms in vascular injury induced by hypertension: Expression and role of microRNA‑34a

“…Vascular injury, including vascular endothelial injury, smooth muscle cell proliferation and vascular remodeling, is the basic pathological change of hypertension diseases (6)(7)(8). A previous study demonstrated that vascular endothelial injury is important in the development of hypertension (9).…”