Long-term outcomes after pulmonary endarterectomy

The long-term outcome of chronic thromboembolic pulmonary hypertension: Pulmonary endarterectomy and balloon pulmonary angioplasty

BACKGROUND

The long-term outcome on patients with chronic thromboembolic pulmonary hypertension (CTEPH) has not been ideal after standard medical treatment. However, good outcome for patients with CTEPH after interventions such as pulmonary endarterectomy (PEA) and balloon pulmonary angioplasty (BPA) has been reported recently. The aim of this study was to evaluate the impact of PEA or BPA on long-term outcomes for CTEPH patients in Han-Chinese population.

METHODS

This was a multicenter, prospective case-control study. Patients with CTEPH were enrolled between January, 2018 and March, 2020. They were divided into two groups, including intervention (PEA or BPA) and conservative groups. The followed-up period was 26 months after treatment. The endpoints were all-cause mortality and CTEPH mortality.

RESULTS

A total of 129 patients were enrolled and assigned to receive PEA/BPA (N = 73), or conservative therapy (N = 56). Overall, the 26-month survival rate of all-cause mortality was significantly higher in intervention group compared to that in conservative group (95.89% vs 80.36%; log-rank p = 0.0164). The similar trend was observed in the 26-month survival rate of CTEPH mortality (97.26% vs 85.71%; log-rank p = 0.0355). Regarding Cox proportional-hazard regression analysis, the hazard ratios (HRs) on patients with CTEPH receiving intervention in the outcome of all-cause mortality and CTEPH mortality were statistically significant (HR = 0.07 and p = 0.0141 in all-cause mortality; HR = 0.11 and p = 0.0461 in CTEPH mortality).

CONCLUSION

This multicenter prospective case-control study demonstrated that intervention such as PEA and BPA increased the long-term survival rate for patient with CTEPH significantly. Intervention was an independent factor in long-term outcome for patients with CTEPH, including all-cause mortality and CTEPH mortality.

Comparison of different treatment strategies in patients with chronic thromboembolic pulmonary hypertension: a single centre real-world experience

BACKGROUND

Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, there is a substantial proportion of patients deemed not operable in whom other treatment strategies are available: medical therapy and balloon pulmonary angioplasty (BPA). We aimed to compare different CTEPH treatment strategies effect in a real-world setting.

METHODS

All patients with CTEPH referred to our centre were included. We compare the short-term clinical, functional, exercise and haemodynamic effect of medical therapy (irrespective of subsequent treatment strategies), PEA and BPA (irrespective of previous/subsequent treatment strategies); we also describe the long-term outcome of the different patient groups.

RESULTS

We included 467 patients (39% were treated only with medical therapy, 43% underwent PEA, 13% underwent BPA and 5% were not treated with any therapy). Patients treated only with medical therapy were the oldest; compared to patients undergoing PEA, they had a lower exercise capacity, a higher risk profile and gained a lower haemodynamic, functional and survival benefit from the treatment. Patients undergoing BPA had a lower haemodynamic improvement but a comparable functional, exercise and risk improvement and a similar survival compared to patients undergoing PEA; their survival is anyway better than patients undergoing only medical treatment. Untreated historical control patients had the worst survival.

CONCLUSIONS

We confirm the superiority of PEA compared to any alternative treatment in CTEPH patients and we observe that BPA, in patients deemed not operable or with persistent/recurrent PH after PEA, leads to a better outcome than medical therapy alone.

Computed Tomography Pulmonary Angiography Prediction of Adverse Long-Term Outcomes in Chronic Thromboembolic Pulmonary Hypertension: Correlation with Hemodynamic Measurements Pre- and Post-Pulmonary Endarterectomy

CT pulmonary angiography is commonly used in diagnosing chronic thromboembolic pulmonary hypertension (CTEPH). This work was conducted to determine if cardiac chamber size on CTPA may also be useful for predicting the outcome of CTEPH treatment. A retrospective analysis of paired CTPA and right heart hemodynamics in 33 consecutive CTEPH cases before and after pulmonary thromboendarterectomy (PTE) was performed. Semiautomated and manual CT biatrial and biventricular size quantifications were correlated with mean pulmonary artery pressure (mPAP), pulmonary vascular resistance (PVR) and cardiac output. The baseline indexed right atrioventricular volumes were twice the left atrioventricular volumes, with significant (p < 0.001) augmentation of left heart filling following PTE. Except for the left atrial volume to cardiac index, all other chamber ratios significantly correlated with hemodynamics. Left to right ventricular ratio cut point <0.82 has high sensitivity (91% and 97%) and specificity (88% and 85%) for identifying significant elevations of mPAP and PVR, respectively (AUC 0.90 and 0.95), outperforming atrial ratios (sensitivity 78% and 79%, specificity 82% and 92%, and AUC 0.86 and 0.91). Manual LV:RV basal dimension ratio correlates strongly with semiautomated volume ratio (r 0.77, 95% CI 0.64-0.85) and is an expeditious alternative with comparable prognostic utility (AUC 0.90 and 0.95). LV:RV dimension ratio of <1.03 and ≤0.99 (alternatively expressed as RV:LV ratio of >0.97 and ≥1.01) is a simple metric that can be used for CTEPH outcome prediction.