Date Published: June 21, 2018
Publisher: Public Library of Science
Author(s): Cécile Tromeur, Xavier Jaïs, Olaf Mercier, Francis Couturaud, David Montani, Laurent Savale, Mitja Jevnikar, Jason Weatherald, Olivier Sitbon, Florence Parent, Dominique Fabre, Sacha Mussot, Philippe Dartevelle, Marc Humbert, Gérald Simonneau, Elie Fadel, Vinicio A. de Jesus Perez.
Few studies have reported predictive factors of outcome after pulmonary endarterectomy (PEA) in chronic thromboembolic pulmonary hypertension. The purpose of this study was to determine factors influencing mortality and predictors of hemodynamic improvement after PEA.
A total of 383 consecutive patients who underwent PEA between January 2005 and December 2009 were retrospectively reviewed. Among them, 150 were fully reevaluated 7.5±1 months after PEA by NYHA class, 6–minute walk distance (6MWD), percentage of predicted carbon monoxide transfer factor (TLCO) and right heart catheterisation.
Mortality rates at 1 month, 1 year and 3 years were 2.8%, 6.9% and 7.5%, respectively. Preoperative pulmonary vascular resistance (PVR) independently predicted 1-month, 1- and 3-year mortality and age predicted mortality at 1 year and 3 years. Significant improvement in NYHA class and 6MWD were observed and PVR decreased from 773±353 to 307±221 dyn.sec.cm-5 (p<0.001). In 96 patients (64%), PVR decreased by at least 50% and/or was reduced to lower than 250 dyn.sec.cm-5. Preoperative cardiac output (CO) and TLCO predicted hemodynamic improvement. PEA is associated with an excellent long-term survival and a marked improvement in clinical status and hemodynamics. Some preoperative factors including PVR, CO and TLCO can predict postoperative outcomes.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare complication of venous thromboembolism and is associated with an important morbidity and mortality. CTEPH results from obstruction of the pulmonary arterial bed by organized thrombus after acute or recurrent pulmonary emboli. Despite the advent of medical therapies  and the emergence of pulmonary angioplasty for CTEPH , the best-established treatment remains pulmonary endarterectomy (PEA), which is usually performed in expert surgical centers . Eligibility criteria for surgery are determined by a multidisciplinary panel of physicians, surgeons and radiologists and are based on the amount of surgically accessible lesions assessed by imaging, the presence of comorbidities and the degree of hemodynamic impairment in symptomatic patients . When successful, PEA markedly improves pulmonary hemodynamics, symptoms and functional status. However, several studies have demonstrated that some patients had persistent pulmonary hypertension (PH) after the procedure [4–7] Persistent PH after surgery represents the most important cause of postoperative morbidity and mortality but there is no consensus on its definition. Some authors used mean pulmonary artery pressure (mPAP) thresholds of 25–30 mmHg [5, 7] whereas others used pulmonary vascular resistance (PVR) thresholds of 500–550 dyn.sec.cm-5 [4, 6, 8], although mPAP≥25mmHg is the accepted definition of PH (3).
This retrospective study complied with the Declaration of Helsinki. Although French law does not require ethics committee approval or informed consent for retrospective data collection, the data was anonymised and complied with the requirements of the Commission Nationale Informatique et Liberté, the organisation dedicated to privacy, information technology, and civil rights in France. The committee approved the methods used to collect and analyse data on May 24, 2003 (approval number 842063).
The present study assessed the factors influencing short- and long-term mortality, the predictors of functional improvement, and the factors predicting improvement or normalization of pulmonary hemodynamics in patients who underwent PEA for CTEPH.