Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension : A Systematic Review

Abstract

Purpose: Pulmonary thromboendarterectomy (PTE) is a treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH). The present systematic review was performed to assess the safety and efficacy of PTE for CTEPH. Methods: A systematic review was performed, and six electronic databases were searched for published studies from January 1999 to February 2010. All articles that presented morbidity and mortality data, survival data or preoperative and postoperative pulmonary hemodynamic indices were included. The primary outcome measures extracted were early morbidity and mortality, pulmonary hemodynamic and functional outcome indices prior to and after the operation, and survival data. Results: Of the 654 publications retrieved, 19 relevant papers (total number of 2729 patients) representing the most recent and complete data set from each institute, were included for appraisal and data extraction. No randomized controlled trials or matched comparative studies were identified. Thirty-day mortality ranged from 1.3% to 24% (median 8%). Residual pulmonary hypertension was reported in 11%-35% of patients after PTE. Pulmonary artery pressure and pulmonary vascular resistance significantly decreased after PTE in all studies. Before PTE, 60%-100% of patients were in NYHA functional class III or IV. This percentage decreased to 0%-21% after PTE. Five-year survival ranged from 74% to 89%. Conclusions: The current literature suggests that PTE for patients with CTEPH is associated with acceptable perioperative morbidity and mortality rates and improved hemodynamic indices and survival when viewed against the prognosis associated with historical controls using medical therapy.

An epidemiological analysis of the burden of chronic thromboembolic pulmonary hypertension in the USA, Europe and Japan

“…A proportion of patients undergoing PEA still experienced pulmonary hypertension after surgery, with the rate of persistent and recurrent pulmonary hypertension following PEA reported in five European studies to be 17-31%, with a weighted average of 30% [5,10,16,17,19]. However, more recently, CANNON et al [56] reported results from a UK national cohort of 880 patients who underwent PEA for CTEPH, showing a post-surgical residual pulmonary hypertension rate of 51%.…”

“…Furthermore, despite the high success rate with PEA, it is not always curative. Among patients undergoing PEA for CTEPH, up to 51% of patients have mean pulmonary arterial pressure >25 mmHg post-PEA [15][16][17][18][19][20].…”

Pulmonary Hemodynamic Response to Exercise in Chronic Thromboembolic Pulmonary Hypertension before and after Pulmonary Endarterectomy

“…Our findings are in accordance with previously published data showing substantial improvement of the pulmonary hemodynamics 1 year after PEA. However, the individual outcome differed and approximately 10-24% of patients remain symptomatic after PEA [9,38] and up to 35% presented with residual PH [12,36,39] .…”

Neutrophil/Lymphocyte Ratio Can Predict Postoperative Mortality in Patients with Chronic Thromboembolic Pulmonary Hypertension

“…The postoperative mortality rate is remarkable and ranges from 1.3 to 24%. 16) Previously researches have been demonstrated that severely affected patients, i.e. mPAP >50 mmHg, cardiac index <2.0 l/min m 2 , pulmonary vascular resistance >1000 dynes ⋅ s ⋅ cm -5 and/or New York Heart Association class IV disease, are at high risk for postoperative bad course and mortality after PEA.…”

“…8) It is now considered to be a distal vasculopathy, in which structural changes caused by vascular remodeling and inflammation play a major role. [6][7][8][9][10][11][12][13][14][15][16][17][18][19] However, the pathophysiologic mechanism of increased PVR has not been well clarified so far.…”