Pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension: hemodynamic characteristics and changes

Objective: To see whether degree of pulmonary hypertension or severity of c ardiac failure affect the success of pulmonary thromboendarterectomy (PTE) in chronic thromboembolic pulmonary hypertension. Methods: From May 1996 to June 1999, 33 patients, all in New York Heart Association (NYHA) class 3 o r 4 were treated with PTE. Preoperative hemodynamic values were: central ve nous pressure (CVP) 8 +/- 6 (1-23), mean pulmonary artery pressure (mPAP) 5 0 +/- 10 (30-69),cardiac output (CO) 3.3 +/- 0.9 (1.8-5.2), pulmonary vascu lar resistance (PVR) 1056 +/- 344 (523-1659); and right ventricle ejection fraction (RVEF) 12 +/- 5 (5-21). To establish whether some hemodynamic or c ardiac variables correlate with surgical failure (early death or functional non-success), these patients were divided into a low risk or a high risk g roup for each variable: CVP (<9 or <greater than or equal to>9), mPAP (<50 or <greater than or equal to>50) CO (greater than or equal to3.5 or <3.5), PVR (<greater than or equal to>1100 or <1100), and RVEF (<greater than or e qual to>10 or <10). The duration of 3-4 NYHA class period (<24 or greater t han or equal to 24 months) was also included in the study. Results: Three p atients (9.1%) died in hospital, one (3.0%) underwent lung transplant short ly after PTE, and in five cases (15.2%) mPAP and PVR at the 3-month follow- up examination corresponded with our definition of functional nonsuccess (m PAP and PVR decreased by less than 40% of preoperative values). One of the five functional nonsuccess patients underwent lung transplant 3 months afte r the operation and another died 17 months after the operation from a non-r elated cause. Thus PTE was successful in 24 patients and unsuccessful in ni ne. None of the hemodynamic variables considered was found to be associated with the disparate outcomes. At the 3-month examination, all surviving pat ients were in NYHA class 1 or 2 except for three in NYHA class 3. At 2 year s, hemodynamic values were: CVP 2 +/- 2 (0-4), mPAP 16 +/- 3 (12-21), CO 5. 0 +/- 1.0 (3.4-6.5), PVR 182 +/- 51 (112-282), and RVEF 35 +/- 5 (26-40). A ll differences were significant with respect to baseline values (P < 0.001) . Preoperative mPAP and RVEF values had a strict linear correlation (R = 0. 45; P = 0.014). Conclusions: None of the variables considered was correlate d with early death or functional nonsuccess. Neither preoperative severity of pulmonary hypertension nor degree of cardiac failure influenced the outc ome of the operation. PTE leads to hemodynamic recovery even in very compro mised patients. (C) 2000 Elsevier Science B.V. All rights reserved.