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Survival After Pulmonary Thromboendarterectomy: Impact Of Residual Pulmonary Hypertension
D. H. Freed1, B. M. Thomson2, S. S. Tsui3, J. Dunning3, K. K. Sheares3, J. Pepke-Zaba3, D. P. Jenkins3. 1University of Manitoba, Winnipeg, MB, Canada, 2Prince Charles Hospital, Brisbane, Australia, 3Papworth Hospital, Cambridge, United Kingdom,
BACKGROUND:
Pulmonary thromboendarterectomy (PTE) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). In many patients hemodynamics are normalized and symptom status improved early after surgery. However, some patients have a more distal vasculopathy and have residual pulmonary hypertension (PH) after PTE. The impact of this residual PH on clinical status and survival is unknown.
METHODS:
Data was collected prospectively on all patients who underwent PTE in a continuous national series between 1997 and June 2006. Post-operatively, patients underwent scheduled reinvestigation including functional testing and right heart catheterization at 3 months after operation, and were divided into 2 groups based on mean pulmonary artery pressure (mPAP): Group 1, mPAP < 30 mmHg; Group 2, mPAP ≥ 30 mmHg. Continuous variables are expressed as mean ± 95% confidence interval. Post-operative variables were compared using chi-square test or t-test where appropriate. Survival was estimated using the Kaplan-Meier method, and compared using the log-rank test.
RESULTS:
Two hundred and thirty patients underwent PTE, survived to hospital discharge and completed follow up. Full hemodynamic data was available on 224 patients (97.4%). At 3 months after PTE, there was a significant reduction in mPAP for the whole cohort (48.8 ± 1.6 to 27.0 ± 1.5 mmHg, p < 0.001). However, 34% of patients had residual PH as defined by mPAP ≥ 30 mmHg. Results are summarized in the table. For the whole cohort, there was a significant improvement in hemodynamics, exercise capacity and symptom status, compared to preop. However, Group 1 patients enjoyed significantly better exercise capacity and improved symptoms compared with group 2. Conditional survival following discharge from hospital for the whole cohort was 93.2% at 5 years, and was not different between groups: 92.8%, Group 1 vs. 94.0%, Group 2 (p = 0.57).
CONCLUSIONS:
For patients undergoing PTE, survival following hospital discharge is excellent. Residual PH significantly comprised symptom status and functional capacity but did not appear to adversely affect medium-term survival.
At 3 months post PTE | Group 1 (n=148) | Group 2 (n=76) | | | mPAP (mmHg) | 20.80 ± 0.76 | 37.96 ± 1.72 | p<0.001 | | PVR (dyne.sec.cm-5) | 180.97 ± 15.98 | 540.69 ± 56.31 | p<0.001 | | CI (L/min/m2) | 2.53 ± 0.09 | 2.42 ± 0.11 | p=0.06 | | Six min walk distance (m) | 395.05 ± 17.22 | 338.94 ± 23.44 | p<0.001 | | NYHA class I or II (n) | 90% (133) | 73% (55) | p<0.001 |
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