Reoperative pulmonary thromboendarterectomy

Background. Recurrent symptomatic pulmonary hypertension is uncommon after primary pulmonary thromboendarterectomy (PTE). We reviewed our experience w ith patients undergoing repeat PTE to determine the risk factors for recurr ent disease, and the selection criteria, relative risks, and functional out comes of reoperative PTE. Methods. Since 1990, 13 of 870 (1.5%) patients underwent reoperative PTE at our institution. These 7 men and 6 women (mean age 38.6 years) were contra sted with the most recent 225 patients (111 men, 114 women, mean age 52.7 y ears) who underwent primary PTE for whom complete hemodynamic data are avai lable. The preoperative evaluation of all patients was similar. Pulmonary h emodynamic data and outcome measures were compared between groups. Results. Of 13 reoperated patients: 69% (9/13) had their primary operation at another institution, 54% (7/13) initially underwent unilateral PTE, 38% (5/13) had identifiable coagulation disorders, 38% (5/13) had ineffective c aval filtration, 31% (4/13) had suboptimal anticoagulation management, and 31% (4/13) had complete unilateral pulmonary artery obstruction. The mean i nterval to reoperation was 5.2 years (range 0.7 to 10.9 years). All control patients underwent bilateral PTE using hypothermic circulatory arrest. Ope rative mortality was 7.7% (1/13) with reoperation vs 8.4% (19/225) in contr ols. No difference (p = NS) was observed between groups in the preoperative pulmonary artery pressure (PAP) or pulmonary vascular resistance; however, the control group had a significantly (p < 0.05) greater reduction in the postoperative PAP (46/19, mean 28 mm Hg vs 59/23, mean 35 mm Hg) and PVR (2 71 +/- 172 vs 399 +/- 154 dynes/s/cm(-5)) compared with the redo group. No substantial difference in morbidity or functional outcomes was observed bet ween groups. Conclusions. Reoperative PTE can be performed with a perioperative risk com parable with primary PTE, although the improvement in pulmonary hemodynamic s is not as favorable. Bilateral primary operation, effective caval filtrat ion, and vigilant anticoagulant management would prevent the need for most reoperative PTEs. (C) 1999 by The Society of Thoracic Surgeons.