Pulmonary Artery Thromboendarterectomy Research Articles

Abstract 1139: Recent Trends And Predictors Of Poor Outcomes In Patients With Chronic Thromboembolic Pulmonary Hypertension Undergoing Pulmonary Artery Thromboendarterectomy.

Introduction: Chronic thromboembolic pulmonary hypertension (CTEPH) occurs due to pulmonary artery obstruction from persistent thromboembolic disease. Pulmonary artery thromboendarterectomy (PTE) is the definitive treatment. In this study, we examine the recent trends, predictors of mortality among patients with CTEPH undergoing PTE. Methods: Using the International Classification of Diseases, 10th edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes, we queried the National Inpatient Sample 2016 to 2020 for hospitalizations among patients ≥18 years old with a diagnosis of CTEPH who underwent PTE. We examined the recent trends in the uptake of PTE, the difference in mortality by year, race, sex, and US region. Logistic regression was used to identify independent predictors of mortality among this cohort of patients. Results: Our study included 18,195 hospitalizations with CTEPH of which 1,790 (9.8%) (mean [SD] age: 54.0 [14.9] years) underwent PTE. In this cohort, 51.7% were males and 47.3% were females. We observed an increasing trend in the uptake of PTE; 7.3%, 27.1%, and 37.4% for the years 2017, 2018, 2019 respectively. This trend reversed in 2020 (28.2%) ( p=0.9 ). Mortality was recorded among 5.9% of patients with CTEPH who had PTE. No difference in mortality was observed by sex/gender, year, race, or hospital region. ECMO was utilized among 8.4% of patients with CTEPH undergoing PTE. Mortality was higher among those who utilized ECMO compared to those who did not utilize ECMO (36.7% vs. 3.1%, p<0.0001). ECMO utilization was identified as an independent predictor of mortality OR: 18.4, 6.96-48.74, P<0.0001. Sex, HTN, and Obesity were not associated with mortality in this cohort. Conclusion: We observe increasing utilization of pulmonary artery thromboendarterectomy among patients hospitalized with CTEPH and increased mortality among those requiring ECMO. Further research is needed to identify predictors of poor outcomes among patients with CTEPH undergoing PTE.

Circulatory support with venovenous ECMO in a patient with reperfusion pulmonary edema after pulmonary artery thromboendarterectomy

Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension characterized by the obstruction of pulmonary arteries secondary to chronic thromboembolism. Pulmonary thromboendarterectomy surgery (PTE) is the main treatment for patients with CTEPH, as it removes the chronic thrombi from the pulmonary arteries. Pulmonary reperfusion syndrome is a common complication of the surgery, which involves the development of pulmonary edema in the area where blood perfusion improves after the surgery. The incidence of this syndrome varies from 8 to 91% depending on the criteria used for diagnosis, and it is one of the most serious complications of pulmonary thromboendarterectomy. In such cases, circulatory support with extracorporeal membrane oxygenation (ECMO) has become a valuable therapeutic modality. We present the case of a 60-year-old woman with a history of acute pulmonary embolism due to deep vein thrombosis of the right pelvic limb who was diagnosed later with CTEPH who was admitted for scheduled surgical treatment involving bilateral PTE. However, during the immediate postoperative period, she developed cardiogenic shock and refractory hypoxemia secondary to pulmonary reperfusion syndrome following the surgical procedure. As a result, she required veno-venous ECMO circulatory support for 6 days, leading to resolution of the pulmonary condition and clinical improvement.

The Pathology of Thromboendarterectomy Specimens from 50 Chronic Thromboembolic Pulmonary Hypertension Patients

Chronic thromboembolic pulmonary hypertension (CTEPH) is a recognized disease where elastic-type pulmonary arteries are narrowed by unresolved pulmonary thrombi. Surgical intervention to remove organized and organizing thrombi is the treatment of choice. We present the histopathologic findings of a cohort of pulmonary artery thromboendarterectomy.

Experience with Inhaled Iloprost Used in the Surgical Treatment of Chronic Postthromboembolic Pulmonary Hypertension

The paper describes a case of inhaled iloprost use in a female patient with severe respiratory failure after pulmonary artery thromboendarterectomy, who was on venovenous extracorporeal membrane oxygenation. To reduce pulmonary hypertension and to prevent reperfusion syndrome, the patient received inhaled iloprost in a dose of 5 ^g every 3 hours during surgery and in the first two days after surgery. On day 14 after surgery, extracorporeal membrane oxygenation was stopped as there were satisfactory respiratory and hemodynamic parameters. Four days later, the patient was weaned from mechanical ventilation. The length of stay in the intensive care unit was 24 days. The patient was discharged from hospital in a satisfactory condition. Thus, the perioperative use of iloprost could reduce pulmonary artery pressure by twice; however, reperfusion syndrome could not prevent significant respiratory failure. The data available in the literature on the use of ilo-prost in patients after pulmonary artery thromboendarterectomy are single and their results are ambiguous. There is a need for large-scale multicenter studies in this group of patients. Key words: chronic postthromboembolic pulmonary hypertension, pulmonary artery thromboendarterectomy, iloprost, extracorporeal membrane oxygenation.

Postoperative management of pulmonary endarterectomy and outcome

Pulmonary artery thromboendarterectomy (PTE) has been regarded as a promising, potentially curative surgical procedure. However, PTE is associated with specific postoperative complications, such as reperfusion pulmonary edema and right heart failure leading to a considerable mortality of 7-24%. Despite its limitations PTE is a better surgical alternative to lung transplantation which carries high morbidity and mortality. The aim of the study is to analyze the efficacy, safety, morbidity and survival associated in the postoperative period and quality of life after six months of PTE in Indian patients. Forty-one patients with surgically correctable chronic thromboembolic pulmonary hypertension underwent pulmonary endarterectomy. All patients were in New York Heart Association (NYHA) Class II, III or IV. Preoperative mean pulmonary artery pressure was 40.98 +/- 9.29 mmHg and mean pulmonary vascular resistance was 418.39 +/- 95.88 dynes/sec/cm(-5). All patients were followed up to six months and a telephonic survey was conducted using a standard questionnaire. They were assessed and classified as per NYHA grading. There was a significant reduction in the mean pulmonary artery pressure (from 40.98 +/- 9.29 mmHg to 24.13 +/- 7.36 mmHg, P < 0.001) and pulmonary vascular resistance (from 418.39 +/- 95.88 dynes/sec/cm(-5) to 142.45 +/- 36.27 dynes/sec/cm(-5), P < 0.001) with a concomitant increase in the cardiac index (from 1.99 +/- 0.20 L/min/m 2 to 3.28 +/- 0.56 L/min/m 2 , P < 0.001) during the postoperative period. The mortality rate in our study was 12.19% (five patients). Ninety per cent of the patients reported a significant improvement in the quality of life and exercise tolerance after surgery compared to the preoperative state. Pulmonary endarterectomy is an effective and potentially curative surgical treatment for patients with severe chronic thromboembolic pulmonary hypertension. The current techniques of operation make the procedure relatively safe and long-term survival, NYHA functional status and exercise capacity improve significantly.

Pulmonary Artery Sarcoma Mimicking Massive Pulmonary Embolus: A Case Report

Intimal sarcomas of the pulmonary artery are rare tumors that are often difficult to distinguish from pulmonary thromboembolic disease, complicating accurate diagnosis and timely therapy. We report the case of a gentleman with a primary pulmonary artery sarcoma who presented with a massive pulmonary embolism and complete right ventricular outflow tract obstruction. The patient's condition was successfully managed with urgent pulmonary artery thromboendarterectomy, pulmonary valve replacement, and tricuspid valve annuloplasty.

Pulmonary thromboendarterectomy for thromboembolic pulmonary hypertension

Pulmonary artery thromboendarterectomy (PTE) is a surgical procedure that offers the only cure for chronic thromboembolic pulmonary hypertension (TPH), a progressive form of secondary pulmonary hypertension. Current estimates indicate that 1% to 5% of patients who survive a pulmonary embolus will develop chronic TPH with progressively worsening pulmonary hypertension and right-sided heart failure. This bilateral procedure is performed through a sternotomy incision using cardiopulmonary bypass, profound hypothermia, and intermittent circulatory arrest with antegrade cerebral perfusion. As an alternative to lung transplantation, PTE offers patients with chronic TPH an improved quality of life.

Dilation of the Coronary Sinus on Echocardiogram: Prevalence and significance in patients with chronic pulmonary hypertension

Although rarely seen in healthy patients, the coronary sinus (CS) is often visualized on echocardiography in patients with right-sided heart disease. However, the prevalence of this finding and its relation to right-sided heart structure and pressure remains undefined. We examined the transthoracic echocardiograms of 43 consecutive patients referred for the evaluation of pulmonary hypertension (26 men, 17 women) with a mean age of 53 +/- 15 years (range 21 to 82 years). Structural abnormalities of the tricuspid valve were absent. All patients underwent right heart catheterization within 48 hours of their echocardiogram, which revealed the following pressures: mean pulmonary artery (50 mm Hg, range 31 to 84 mm Hg) and right atrial (RA) (mean 10, range 1 to 24 mm Hg). Echocardiograms were analyzed for CS size (identified as the smallest diameter of a circular structure in the left atrioventricular groove in the parasternal long-axis view), as well as RA and right ventricular (RV) sizes. The presence and severity (grades 1 through 3) of tricuspid regurgitation (TR) were also recorded. The CS was visualized in 35 (81%) of 43 patients, and measurements ranged from 0.4 to 1.6 cm (mean 0.8 cm). No difference in RA size, RV size, TR grade, RA pressure (RAP), RV pressure (RVP), mean pulmonary artery pressure (PAP), or pulmonary vascular resistance (PVR) was observed between patients with a visualized and nonvisualized CS. Coronary sinus size correlated significantly with RA size (r = 0.60, P <.001) and pressure (r = 0.59, P <.001), but not with RV size, degree of TR, RVP, PAP, or PVR. Nineteen of 35 patients with a visualized CS underwent pulmonary artery thromboendarterectomy (PTE), and their CS size and RAP were unchanged (0.8 cm and 12 mm Hg, respectively, preand post-PTE; both P = NS [not significant]), though a decrease was observed in other measurements: RA size (4.2 versus 4.8 cm, P =.02), RV size (4.2 versus 5.1 cm, P =.0004), mean PAP (37 versus 72 mm Hg, P <.0001), and PVR (230 versus 899 mm Hg, P <.0001). Coronary sinus dilation was observed in 81% of a selected group of patients with pulmonary hypertension in the absence of structural disease of the tricuspid valve. Coronary sinus dilation is related to RAP and RA size, but not to RV size, degree of TR, RVP, PA pressure, or PVR. Once dilated, CS size does not change shortly after decreases of RA size, RV size, or PA pressure produced by PTE.

Pulmonary Artery Thromboendarterectomy: A Comparison of Two Different Postoperative Treatment Strategies

Pulmonary artery thromboendarterectomy (PTE) is a potentially curative surgical procedure for chronic thromboembolic pulmonary hypertension. It is, nevertheless, associated with considerable mortality caused by postoperative complications, such as reperfusion pulmonary edema (RPE) (i.e., pulmonary infiltrates in regions distal to vessels subjected to endarterectomy) and right heart failure (RHF). However, there are no reports about the influence of different postoperative treatment strategies on complications and mortality. Therefore, we compared two different treatment strategies. In Group I (n = 33), positive inotropic catecholamines and vasodilators were avoided during termination of cardiopulmonary bypass (CPB) and thereafter, and mechanical ventilation was performed with low tidal volumes < 8 mL/kg, duration of inspiration:duration of expiration = 3:1, and peak inspiratory pressures < 18 cm H2O. In Group II (n = 14), positive inotropic catecholamines and vasodilators were regularly used for termination of CPB and thereafter, and ventilation was performed with high tidal volumes (10–15 mL/kg) and peak inspiratory pressures up to 50 cm H2O. Hemodynamics, the incidence of RPE and RHF, duration of ventilation, morbidity, and mortality were recorded. Cardiac index was comparable before surgery (2.11 ± 0.09 vs 2.08 ± 0.09 L · min−1 · m−2) and 20 min after CPB (2.26 ± 0.09 vs 2.60 ± 0.20 L · min−1 · m−2). RPE occurred in 6.1% (Group I) versus 14.3% (Group II), and RHF was observed in 9.1% (Group I) versus 21.4% (Group II). Mortality was 9.1% (Group I) versus 21.4% (Group II). Thus, the avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation after PTE was associated with a low incidence of RPE, RHF, duration of ventilation, and mortality after PTE. Implications The avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation was associ- ated with a low incidence of reperfusion pulmonary edema and/or right heart failure after pulmonary artery thromboendarterectomy.

Thromboembolic Obstruction of the Pulmonary Artery Treated by Endarterectomy

Endarterectomy of a totally occluded right pulmonary artery by median sternotomy with cardiopulmonary bypass and intermittent circulatory arrest is described. The nature of the thrombus encountered and brisk backbleeding from the endarterectomized vessels predicted the functional improvement seen in the patient postoperatively. Reperfusion edema, which often complicates pulmonary artery thromboendarterectomy, was not observed. Preoperative assessment, postoperative management, and technical aspects of the operative procedure used in treating patients with thromboembolic obstruction of the pulmonary arteries are discussed.