Abstract
BackgroundPulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons. Starting a new program allows an opportunity to define a learning curve for PTE.MethodsA retrospective case review was performed of 134 consecutive PTEs performed from 1998 to 2016 at a single institution. Outcomes were compared using either a two-tailed t-test for continuous variables or a chi-squared test for categorical variables according to experience of the program by terciles (T).ResultsThe 30-day mortality was 3.7%. The mean length of hospital stay, length of ICU stay, and duration on a ventilator were 12.6 days, 4.6 days, and 2.0 days, respectively. The mean decrease in systolic pulmonary artery pressure (sPAP) was 41.3 mmHg. Patients with Jamieson type 2 disease had a greater change in mean sPAP than those with type 3 disease (p = 0.039). The mean cardiopulmonary bypass time was 180 min (T1–198 min, T3–159 min, p = <0.001), and the mean circulatory arrest time was 37 min (T1-44 min, T3-31 min, p < 0.001). Plotting circulatory arrest times as a running sum compared to the mean demonstrated 2 inflection points, the first at 22 cases and the second at 95 cases.ConclusionsPTE is a challenging procedure to learn, and good outcomes are a result of a multi-disciplinary effort to optimize case selection, operative performance, and postoperative care. Approximately 20 cases are needed to become proficient in PTE, and nearly 100 cases are required for more efficient clearing of obstructed pulmonary arteries.
Highlights
Pulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons
Chronic thromboembolic pulmonary hypertension (CTEPH) is a relatively rare disease affecting less than 5% of patients subsequent to an acute pulmonary embolism [1]
Riedel et al reported that patients with mean pulmonary artery pressures greater than 30 mmHg have only a 30% 5-year survival, and in patients with mean Pulmonary artery pressure (PAP) greater than 50 mmHg, 5-year survival further decreases to as low as 10% [2]
Summary
Pulmonary thromboendarterectomy (PTE) is an effective treatment for chronic thromboembolic pulmonary hypertension (CTEPH), but is a technically challenging operation for cardiothoracic surgeons. Chronic thromboembolic pulmonary hypertension (CTEPH) is a relatively rare disease affecting less than 5% of patients subsequent to an acute pulmonary embolism [1]. It is characterized by pulmonary hypertension resulting from pulmonary vascular obstruction which leads to progressive right ventricular dysfunction. The effectiveness of the operation is directly related to the location and accessibility of pulmonary arterial occlusive disease and the extent to which it is cleared by the surgeon [5] It is performed predominantly at a few experienced centers across the country, and these centers have been able to demonstrate excellent outcomes in appropriately selected patients. The group at University of California San Diego Medical Center (UCSD) has reported the largest experience with PTE with an overall mortality rate of 4.9% and a mean decrease in pulmonary artery systolic pressures of 28 mmHg correlating
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