Hipertensión pulmonar tromboembólica crónica: tratamiento mediante tromboendarterectomía quirúrgica

Pulmonary thromboendarterectomy in 106 patients with chronic thromboembolic pulmonary hypertension

INTRODUCTION

Pulmonary thromboendarterectomy is the treatment of choice in chronic thromboembolic pulmonary hypertension. We report our experience with this technique.

METHODS

Between February 1996 and June 2014, we performed 106 pulmonary thromboendarterectomies. Patient population, morbidity and mortality and the long-term results of this technique (survival, functional improvement and resolution of pulmonary hypertension) are described.

RESULTS

Subjects' mean age was 53±14 years. A total of 89% were WHO functional class III-IV, presurgery mean pulmonary pressure was 49±13mmHg and mean pulmonary vascular resistance was 831±364 dynes.s.cm(-5). In-hospital mortality was 6.6%. The most important post-operative morbidity was reperfusion pulmonary injury, in 20% of patients; this was an independent risk factor (p=0.015) for hospital mortality. With a 31-month median follow-up (interquartile range: 50), 3- and 5-year survival was 90 and 84%. At 1 year, 91% were WHO functional class I-II; mean pulmonary pressure (27±11mmHg) and pulmonary vascular resistance (275±218 dynes.s.cm(-5)) were significantly lower (p<0.05) than before the intervention. Although residual pulmonary hypertension was detected in 14 patients, their survival at 3 and 5 years was 91 and 73%, respectively.

CONCLUSIONS

Pulmonary thromboendarterectomy offers excellent results in chronic thromboembolic pulmonary hypertension. Long-term survival is good, functional capacity improves, and pulmonary hypertension is resolved in most patients.

[Pulmonary circulation: contributions of the year 2009]

A significant number of studies on pulmonary circulation diseases have been published in 2009 that are likely to have a notable clinical impact. Anticoagulant treatment is on the verge of a significant change with the arrival of new oral drugs that have an inhibitory effect over factor X (rivaroxaban, apixaban) or thrombin (dabigatran). New studies have shown an efficacy comparable to enoxaparin in the prevention of thromboembolic disease and in some cases a lower risk of haemorrhage. Also interesting is a study on the incidence of pulmonary thromboembolism in patients with chronic obstructive pulmonary disease, a little known aspect. A study that demonstrates some efficacy of rosuvastatin in the prevention of thromboembolic disease, something that could change our current practices. Pulmonary hypertension (PH) continues to produce numerous publications. One French study has shown a relatively low risk of developing PH in patients with systemic sclerosis over a period of 3 years. As regards treatment, ambrisentan seems to confirm it lower risk of hepatoxicity compared to other endothelin antagonists. A new phosphodiesterase-5 inhibitor, tadalafil, has made a strong impact on the PH scene during this year. Its results are similar to other oral drugs with a convenient posology. The surgical treatment of PH due to chronic thromboembolism in one of the hospitals of our country has been present with results that, particularly in the past few years, are perfectly comparable to other centres of excellence. To summarise, 2009 has continued to provide important news in the area of pulmonary circulation.