Symptoms Are More Useful Than Echocardiography in Patient Selection for Pulmonary Endarterectomy

Abstract

Patients with mild CTEPH can benefit from PEA, but may not be detected by TTE. Symptomatic patients with functional limitation and persistent mismatched perfusion defects on VQ scan should undergo further investigations with pulmonary angiogram and RHC.

Exercise right heart catheterisation before and after pulmonary endarterectomy in patients with chronic thromboembolic disease

“…In CTEPH, as in pulmonary arterial hypertension, ZHAI et al [35] demonstrated that the ventilatory efficiency is impaired and highlighted that for CTEPH there was no correlation to the functional classes; however, no CTED patients were included in their report. DONAHOE et al [7] demonstrated increased ventilatory equivalents for carbon dioxide at anaerobic threshold and peak exercise similar to the results for our patients, but no post-operative data exist. One case report of CTED described improvements in right ventricular performance and ventilatory efficiency following PEA, but no exercise RHC data were mentioned [36].…”

“…These patients have symptoms like dyspnoea upon exertion or fatigue that hamper their daily activities and diminish their quality of life. CTED patients show the same exercise limitations and symptoms as World Health Organization (WHO) Functional Class II or III CTEPH patients as described by DONAHOE et al [7]. These symptoms are in line with an inadequate response in pulmonary haemodynamics during exercise [8][9][10].…”

“…This was accompanied by a higher mortality in the borderline group. DONAHOE et al [7] reported one of 22 CTED patients with progression to CTEPH requiring lung transplantation, suggesting a realistic risk of worsening. However, larger studies providing evidence for the prognostic relevance of exercise pulmonary hypertension in CTED are needed.…”

“…The rationale for PEA in operable CTED patients is improvement of their quality of life by improving symptoms and exercise tolerance as reported by TABOADA et al [9] and van KAN et al [10]. In addition, with early treatment, potential long-term complications like the development of secondary small-vessel vasculopathy and right heart failure can be avoided [1,7,11]. Recently, a report of a multicentre registry of inoperable CTED patients was published that showed improvements in physical capacity and PVR after balloon pulmonary angioplasty, but no exercise data were reported [12].…”

Diagnosis of chronic thromboembolic pulmonary hypertension: A Canadian Thoracic Society clinical practice guideline update

“…In the aforementioned meta-analysis, 3 of the 14 studies which confirmed CTEPH by RHC, 4,7,8,[11][12][13][14][15][16]18,19,21,23,26 9 studies had screened all included patients with echo, 8,11,12,[14][15][16]18,21,26 whereas echo was only performed in patients reporting dyspnea in 4 other studies. 4,7,13,23 Overall, systematic screening did not increase CTEPH detection rate, as the incidence of CTEPH was the same whether all patients were screened post-PE or only symptomatic patients were investigated.…”