Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension

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Background

Management and outcome of patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) who underwent pulmonary endarterectomy (PEA) at a large German referral center were investigated.

Methods

In Germany, 394 PEAs were performed in 2014 and 2015 with an in-hospital mortality rate of 5.8%. Of these, 253 patients (64.2%) were treated at the Kerckhoff Clinic, Bad Nauheim, and 237 (93.7%; median age, 62 years [interquartile range [IQR], 52–72 years]; 46.0% female) were included in the present analysis.

Results

On referral, 52 patients (22.0%) were treated with pulmonary arterial hypertension–specific drugs and 95 (40.4%) were treated with non–vitamin K–dependent oral anticoagulants, and 14 (5.9%) had mean pulmonary artery pressure <25 mm Hg and were classified as having chronic thromboembolic pulmonary vascular disease. PEA was feasible in 236 (99.6%) patients with median duration of surgery of 397 minutes (IQR, 363–431 minutes). Periprocedural (0%) and in-hospital (2.5%) mortality rates were very low. Forty-two patients (17.7%) had intraoperative complications, and 60 (25.3%) had post-operative complications. The duration of surgery was the only predictor of in-hospital mortality (≥500 minutes; odds ratio [OR], 32.0; 95% confidence interval [CI], 5.5–187.6) and the only independent predictor of intraoperative (≥440 minutes; OR, 10.8; 95% CI, 4.4–26.5) and post-operative (≥390 minutes; OR, 2.4; 95%CI, 1.1–5.7) complications. Only intraoperative complications independently predicted a longer duration of surgery (≥397 minutes; OR, 5.0; 95% CI, 2.2–11.2).

Conclusions

In an experienced center with multidisciplinary diagnostic and therapeutic approaches, PEA is safe. Prognosis was mainly determined by occurrence of intraoperative complications and duration of surgery rather than patients’ pre-operative status.

Section snippets

Methods

All patients admitted to the Kerckhoff Clinic, Bad Nauheim, Germany, for scheduled PEA between January 2014 and December 2015 were considered eligible for inclusion in the present prospective, non-interventional cohort study. The Kerckhoff Clinic serves as a national referral center for PEA, with >100 PEA procedures performed per year. The diagnosis of CTEPH was established by the referring physician (in most cases at national PH expert centers) according to current guidelines.16 Operability

Patient cohort

Between January 1, 2014, and December 31, 2015, 253 patients with CTEPH underwent PEA (alone or in combination with BPA); 237 (93.7%) of these patients were included in the study (Figure 1). Patients excluded did not differ with regard to baseline characteristics, symptoms, functional status, medication, risk factors for CTEPH, comorbidities, and outcome (data not shown). Most of the patients (219 [92.4%]) were transferred to Bad Nauheim from centers in Germany, and 18 further patients were

Discussion

PEA is the only potentially curative treatment for patients with CTEPH.1, 5, 6, 7, 8 During the past decade, improvements in surgical techniques and supportive intensive care and, most importantly, understanding of the importance of interdisciplinary team approaches in experienced PEA centers have resulted in decreased in-hospital mortality rates after PEA. In the most recently operated patients, 2 of the largest PEA centers worldwide reported favorable in-hospital mortality rates of 2.2% and

Disclosure statement

None of the authors reports a conflict of interest related to the submitted work. The following authors report financial activities outside the submitted work: M.L. reports having received consultancy and lecture honoraria from Actelion, Bayer, Daiichi-Sankyo, MSD, Pfizer, and Bristol-Myers-Squibb C.L. reports having received lecture honoraria from Abbott, Astra Zeneca, Bayer, Berlin Chemie, Boehringer Ingelheim, Daiichi-Sankyo, Pfizer, and Bristol-Myers-Squibb and payment for travel

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    These authors have contributed equally to this work.

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