Residual Pulmonary Hypertension After Pulmonary Endarterectomy: The Fog Is Clearing.

Abstract

Surgical pulmonary endarterectomy (PEA) is unanimously considered the preferred treatment for chronic thromboembolic pulmonary hypertension (CTEPH),1–4 even though there has never been a randomized, controlled study evaluating the safety and efficacy of this approach. This is readily explained by the fact that CTEPH is often a rapidly fatal disease if left untreated.5,6 PEA was developed in the early seventies of the past century,7 and it remained the only treatment for CTEPH for nearly 40 years. In several countries, centers of expertise emerged and the results of surgery improved constantly. At the University of California, San Diego, the postoperative mortality in the first 143 patients who underwent PEA surgery between 1970 and 1998 was 16.8%.8 This figure dropped to 2.2% in the 500 patients operated on between October 2006 and December 2010.8 Article, see p 1761 Although information on postoperative mortality of PEA surgery was readily available, the picture was somewhat foggy when it came to postoperative morbidity. Most patients had substantial hemodynamic and functional improvements after surgery, but systematic long-term follow-up data were scarce. Although PEA was considered a curative approach, it was noted early on that some patients had residual or recurrent pulmonary hypertension after surgery.9 However, given the lack of systematic and coordinated follow-up strategies, the incidence and clinical relevance of residual pulmonary hypertension remained largely unknown. There was not even a uniform definition of residual pulmonary hypertension after surgery. Research groups looking at the postoperative course after PEA have used mean pulmonary artery pressure (PAPm) thresholds of 25 …