Pulmonary endarterectomy: Potentially curative treatment for patients
with chronic thromboembolic pulmonary hypertension
ROQUE A BALDASARIA, HÉCTOR L LUCIARDI
3era Cátedra de Patología y Clínica Médica. Facultad de Medicina. UNT
Hospital Centro de Salud “Zenón J Santillán”
(4000) San Miguel de Tucumán, Argentina. E-mail
Recibido 17-OCT-2018 – ACEPTADO 27 de OCTUBRE de 2018.
There are no conflicts of interest to disclose.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive and devastating disease if not treated timely. It belongs to a unique subtype of potentially curable pulmonary hypertension . CTEPH is a result of the fibrotic transformation of thrombi in the pulmonary artery tree that causes chronic obstruction and microvasculature remodeling; and consequently, increase in pressure and resistance in pulmonary vasculature, finally leading to right heart failure and premature mortality .
The diagnosis of CTEPH requires 3 months of effective anticoagulation and a mean pulmonary artery pressure (MPAP) >25 mmHg, with pulmonary capillary wedge pressure ≤15 mmHg, and at least one segmental perfusion defect .
Pulmonary endarterectomy (PEA) offers, as a therapeutic alternative, the best possibility of symptomatic and prognostic improvement in eligible patients, with excellent results in the long term, in expert centers . The guidelines by the European Society of Cardiology and the European Respiratory Society recommend pulmonary endarterectomy as the treatment of choice for patients with CTEPH.
Not all patients will be eligible for PEA, and factors like an advanced age, co-morbidities, imbalance between pulmonary vascular resistance increase and the number of accessible occlusions, deficient general condition of the patient, should be considered to determine the chances to operate . To be considered operable, a patient should have enough surgically accessible thromboembolic material, with a proportional pulmonary vascular resistance, that would indicate absence of extensive secondary vasculopathy.
The multidisciplinary team in charge of the treatment should include at least one experienced surgeon, understanding as such, someone with at least 20 pulmonary endarterectomies performed the previous year and/or >40 PEA within 3 years before the study cases started to be evaluated. Thromboembolic disease located proximally in the main, lobar or segmental arteries is susceptible of PEA in most surgical centers; not so distal disease of segmental and subsegmental branches, which are more challenging for the surgeon .
The surgical classification of CTEPH, redefined by the University of California, San Diego (UCSD), was specifically developed to treat distal thromboembolic disease, with a capacity to differentiate 5 levels of disease location, segmental and subsegmental .
In light of the PEA surgical technique requiring a properly trained multidisciplinary team, at least one experienced surgeon, specialized training, deep hypothermic circulatory arrest, and sophisticated postsurgical intensive care, the experience and results presented by Talavera et al, of the Instituto Cardiovascular de Buenos Aires in this issue of the Revista de FAC , are really encouraging. See the paper published
Some reference centers even propose PEA for selected patients with symptomatic chronic thromboembolic disease with no pulmonary hypertension , to improve symptoms and quality of life, with encouraging results in evaluation at 6 and 12 months after the intervention.
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