Pulmonary Thromboendarterectomy: Patient Selection, Techniques, Outcomes, and Recent Advances

Abstract

Chronic ThromboEmbolic Pulmonary Hypertension (CTEPH) is a potentially curative form of pulmonary hypertension, which continues to be underdiagnosed. Pulmonary ThromboEndarterectomy (PTE, also referred to as PEA for Pulmonary Endarterectomy) is a technically challenging procedure that requires careful patient selection, meticulous surgical techniques, and expertise in postoperative care. Over the last decade, there have been significant advances not only in the techniques of the operation, but also in the postoperative management of major complications. Furthermore, advances have been made not only in medical therapy, but also in percutaneous interventions, in the form of balloon pulmonary angioplasty (BPA). BPA and medical therapy are considered to be palliative; they are reserved for patients who are inoperable, or for those who continue to have symptomatic PH postoperatively. PTE remains the gold standard treatment for CTEPH, as long as the patient has evidence of surgically accessible disease, and the patient has acceptable surgical risk. All CTEPH patients should be evaluated and considered for surgery, and no patient should be turned down without consultation with a multidisciplinary team at an expert center. Furthermore, no amount of PH or degree of right heart failure is a contraindication to surgery, as long as there is corresponding level of disease. Excellent short- and long-term results can be achieved with current data suggesting significant advantage with 10-yr survival of 85–90%.