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Malik M, Malik S, Karur GR, Mafeld S, de Perrot M, McInnis MC. Cardiothoracic Imaging for Outcome Prediction in Chronic Thromboembolic Pulmonary Hypertension after Pulmonary Endarterectomy or Balloon Pulmonary Angioplasty: A Scoping Review. J Clin Med 2024; 13:5045. [PMID: 39274257 PMCID: PMC11395896 DOI: 10.3390/jcm13175045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 08/16/2024] [Accepted: 08/19/2024] [Indexed: 09/16/2024] Open
Abstract
There has been a rapid expansion in centers performing balloon pulmonary angioplasty (BPA) and pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH). The purpose of this scoping review was to identify cardiothoracic imaging predictors of outcomes and to identify gaps to address in future work. A scoping review was conducted using the framework outlined by Arksey and O'Malley and Levac et al. in MEDLINE and EMBASE. The study protocol was preregistered in OSF Registries and performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-ScR) guidelines. There were 1117 identified studies, including 48 involving pulmonary thromboendarterectomy (n = 25) and balloon pulmonary angioplasty (n = 23). CT was the most common preoperative imaging modality used (n = 21) and CT level of disease was the most reported imaging predictor of outcomes for pulmonary thromboendarterectomy. Although must studies evaluated hemodynamic improvements, imaging was of additional use in predicting clinically significant procedural complications after balloon pulmonary angioplasty, as well as mortality and long-term outcome after pulmonary endarterectomy. Predictors reported in MRI and digital subtraction angiography were less commonly reported and warrant multicenter validation. Cardiothoracic imaging may predict clinically significant outcomes after balloon pulmonary angioplasty and pulmonary thromboendarterectomy. Radiologists involved in the assessment of CTEPH patients should be aware of key predictors and future investigations could focus on multicenter validation and new technologies.
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Affiliation(s)
- Mikail Malik
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Shamir Malik
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON M5S 1A8, Canada
| | - Gauri R Karur
- University Medical Imaging Toronto, Toronto General Hospital, Toronto, ON M5G 2C4, Canada
- Division of Cardiothoracic Imaging, Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Sebastian Mafeld
- University Medical Imaging Toronto, Toronto General Hospital, Toronto, ON M5G 2C4, Canada
- Division of Interventional Radiology, Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Department of Surgery, Toronto General Hospital, Toronto, ON M5G 2C4, Canada
| | - Micheal C McInnis
- University Medical Imaging Toronto, Toronto General Hospital, Toronto, ON M5G 2C4, Canada
- Division of Cardiothoracic Imaging, Department of Medical Imaging, University of Toronto, Toronto, ON M5T 1W7, Canada
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Chan JCY, Man HSJ, Asghar UM, McRae K, Zhao Y, Donahoe LL, Wu L, Granton J, de Perrot M. Impact of sex on outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2023; 42:1578-1586. [PMID: 37422146 DOI: 10.1016/j.healun.2023.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 06/06/2023] [Accepted: 06/07/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The impact of sex on long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (PH) remains unclear. We therefore examined the early and long-term outcome after PEA to determine whether sex had an impact on the risk of residual PH and need for targeted PH medical therapy. METHODS Retrospective study of 401 consecutive patients undergoing PEA at our institution between August 2005 and March 2020 was performed. Primary outcome was the need for targeted PH medical therapy postoperatively. Secondary outcomes included survival and measures of hemodynamic improvement. RESULTS Females (N = 203, 51%) were more likely to have preoperative home oxygen therapy (29.6% vs 11.6%, p < 0.01), and to present with segmental and subsegmental disease compared to males (49.2% vs 21.2%, p < 0.01). Despite similar preoperative values, females had higher postoperative pulmonary vascular resistance (final total pulmonary vascular resistance after PEA, 437 Dynes∙s∙cm-5 vs 324 Dynes∙s∙cm-5 in males, p < 0.01). Although survival at 10 years was not significantly different between sexes (73% in females vs 84% in males, p = 0.08), freedom from targeted PH medical therapy was lower in females (72.9% vs 89.9% in males at 5 years, p < 0.001). Female sex remained an independent factor affecting the need for targeted PH medical therapy after PEA in multivariate analysis (HR 2.03, 95%CI 1.03-3.98, p = 0.04). CONCLUSIONS Although outcomes are excellent for both sexes, females had greater need for targeted PH medical therapy in the long-term. Early reassessment and long-term follow-up of these patients are important. Further investigations into possible mechanisms to explain the differences are warranted.
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Affiliation(s)
- Justin C Y Chan
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada; Department of Cardiothoracic Surgery, New York University Langone Health, New York, New York
| | - H S Jeffrey Man
- Department of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Usman M Asghar
- Latner Thoracic Research Laboratories, Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Karen McRae
- Department of Anaesthesia and Pain Medicine, University Health Network, Toronto, Ontario, Canada
| | - Yidan Zhao
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Laura L Donahoe
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Licun Wu
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - John Granton
- Department of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada.
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Zhang X, Guo X, Zhang B, Yang Q, Gong J, Yang S, Li J, Kuang T, Miao R, Yang Y. The Role of Strain by Cardiac Magnetic Resonance Imaging in Predicting the Prognosis of Patients with Chronic Thromboembolic Pulmonary Hypertension. Clin Appl Thromb Hemost 2023; 29:10760296231176253. [PMID: 37700697 PMCID: PMC10501068 DOI: 10.1177/10760296231176253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/13/2023] [Accepted: 04/28/2023] [Indexed: 09/14/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by thrombotic obstruction of the pulmonary arteries, and right ventricular (RV) dysfunction is a major cause of death. Cardiac magnetic resonance (CMR) is the gold standard for assessing heart wall deformation; therefore, we aimed to determine the prognostic value of CMR strain in patients with CTEPH. Strain derived by CMR was measured at the time of diagnosis in 45 patients with CTEPH, and the relationship between RV strain and prognosis was determined through follow-up. The value of RV strain in the prognostic model was compared with that of pulmonary arterial hypertension (PAH) risk stratification. The RV global peak longitudinal strain (GLS) and global peak circumferential strain (GCS) in CTEPH patients were lower than the normal references of RV strain in the control group. GLS and longitudinal strain in the basal segment were independent risk factors for adverse events (P < .050). Adding CMR parameters to PAH risk stratification improved its predictive power in patients with CTEPH. GLS and GCS scores were impaired in patients with chronic RV overload. RV strain derived by CMR imaging is a promising noninvasive tool for the follow-up of patients with CTEPH.
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Affiliation(s)
- Xuefei Zhang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Xiaojuan Guo
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Bowen Zhang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Qi Yang
- Department of Radiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
| | - Juanni Gong
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Suqiao Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Jifeng Li
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Tuguang Kuang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Ran Miao
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
| | - Yuanhua Yang
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Medical Research Center, Beijing Institute of Respiratory Medicine and Beijing Chao-Yang Hospital, Capital Medical University, Beijing, PR China
- Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Institute of Respiratory Medicine, Beijing, China
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Kunihara T, Wilkens H, Halank M, Held M, Nomura R, Igarashi T, Sata F, Schäfers HJ. Haemodynamic benefit of bridging use of bosentan prior to pulmonary endarterectomy. Eur J Cardiothorac Surg 2021; 60:840-847. [PMID: 33755096 DOI: 10.1093/ejcts/ezab137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 02/09/2021] [Accepted: 02/14/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Some patients present with excessive pulmonary hypertension (PH) prior to pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). This study was performed to evaluate the clinical role of pretreatment before PEA in CTEPH patients. METHODS A total of 370 patients with CTEPH undergoing first PEA between 2003 and 2017 were divided into those receiving pretreatment with bosentan (group B: n = 119) and those without targeted pretreatment for PH (group C: n = 251). After selecting patients given bosentan (2-8 months) and using propensity score matching, comparable patient cohorts (n = 23 each) were created from both groups. PEA was performed in the standard manner, and the median number of extracted segments was 14. RESULTS There were no significant differences in perioperative demographic characteristics or 30-day mortality (overall 5.7%) between the groups before and after matching. In patients with preoperative pulmonary vascular resistance (PVR) ≥800 dynes s/cm5, a significantly larger decrease in PVR was found in group B (78%) compared to group C (68%) (P = 0.033). There was no significant difference in late survival between the groups after matching. The frequency of residual/persistent PH (mean pulmonary artery pressure >25 mmHg) was lower in group B than in group C, although the difference was not significant (22% vs 39%, respectively, P = 0.200). Advanced age and longer cardiopulmonary bypass time were independent predictors of both 30-day mortality and residual/persistent PH (odds ratio: age, 1.053, 1.013, cardiopulmonary bypass time, 1.065, 1.010, respectively). CONCLUSIONS Preoperative treatment of CTEPH patients with bosentan for 2-8 months can improve post-PEA PVR without adverse clinical events in patients with a high preoperative PVR. A temporary bridging regime appears beneficial in selected patients prior to PEA.
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Affiliation(s)
- Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine, Tokyo, Japan
| | - Heinrike Wilkens
- Department of Pulmonary Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Michael Halank
- Department of Internal Medicine I, Pneumology, University Hospital Dresden, Dresden, Germany
| | - Matthias Held
- Department of Internal Medicine and Respiratory Care, Mission Medical Hospital, Würzburg, Germany
| | - Ryota Nomura
- Department of Cardiovascular Surgery, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | - Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | | | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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Miyahara S, Schröder TA, Wilkens H, Karliova I, Langer F, Kunihara T, Schäfers HJ. An Evaluation of the Learning Curve in Pulmonary Endarterectomy Using Propensity Score Matching. Thorac Cardiovasc Surg 2020; 69:284-292. [PMID: 32886927 DOI: 10.1055/s-0040-1714747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Pulmonary endarterectomy (PEA) is the only causative, but demanding treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). We analyzed our results with PEA to evaluate the learning curve. METHODS Consecutive 499 patients who underwent PEA between 1995 and 2014 were divided into two groups according to the temporal order: early cohort (n = 200, December 1995-March 2006), and late cohort (n = 299, March 2006-December 2014). We assessed perioperative outcomes after PEA as compared between the early and the late cohort also in propensity-score-matched cohorts. RESULTS Age at the surgery was older in the late cohort (p = 0.042). Preoperative mean pulmonary artery pressure (mPAP) was 46.8 ± 11.0 mm Hg in the early cohort and 43.5 ± 112.7 mm Hg in the late cohort (p = 0.0035). The in-hospital mortality in the early and late cohorts was 14.0% (28/200) and 4.7% (14/299), respectively (p = 0.00030). The duration of circulatory arrest (CA) became much shorter in the late cohort (42.0 ± 20.5 min in the early and 24.2 ± 11.6 min in the late cohort, respectively, p < .0001). In matched cohorts, the in-hospital mortality showed no significant difference (8.7% in the early cohort and 5.2% in the late cohort, < 0.0001). The CA duration, however, was still shorter in the late cohort (p <0.0001). CONCLUSIONS Over time, older patients have been accepted for surgery, more patients were operated for lesser severity of CTEPH. Duration of CA and mortality decreased even beyond the first 200 patients, indicating a long learning curve.
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Affiliation(s)
- Shunsuke Miyahara
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Tom A Schröder
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Heinrike Wilkens
- Department of Internal Medicine V, Saarland University Medical Center, Homburg, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Frank Langer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
| | - Takashi Kunihara
- Department of Cardiac Surgery, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Saarland, Germany
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The Clinical Significance of HbA1c in Operable Chronic Thromboembolic Pulmonary Hypertension. PLoS One 2016; 11:e0152580. [PMID: 27031508 PMCID: PMC4816563 DOI: 10.1371/journal.pone.0152580] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 03/16/2016] [Indexed: 01/30/2023] Open
Abstract
Background Glycosylated hemoglobin A1c (HbA1c) has been proposed as an independent predictor of long-term prognosis in pulmonary arterial hypertension. However, the clinical relevance of HbA1c in patients with operable chronic thromboembolic pulmonary hypertension (CTEPH) remains unknown. The aim of the present study was to investigate the clinical significance of HbA1c as a biomarker in CTEPH. Methods Prospectively, 102 patients underwent pulmonary endarterectomy (PEA) in our national referral center between March 2013 and March 2014, of which after exclusion 45 patients were analyzed. HbA1c- levels, hemodynamic and exercise parameters were analyzed prior and one-year post-PEA. Results 45 patients (BMI: 27.3 ± 6.0 kg/m2; age: 62.7 ± 12.3 years) with a mean pulmonary arterial pressure (mPAP) of 43.6 ± 9.4 mmHg, a pulmonary vascular resistance (PVR) of 712.1 ± 520.4 dyn*s/cm5, a cardiac index (CI) of 2.4 ± 0.5 l/min/m2 and a mean HbA1c-level of 39.8 ± 5.6 mmol/mol were included. One-year post-PEA pulmonary hemodynamic and functional status significantly improved in our cohort. Baseline HbA1c-levels were significantly associated with CI, right atrial pressure, peak oxygen uptake and the change of 6-minute walking distance using linear regression analysis. However, using logistic regression analysis baseline HbA1c-levels were not significantly associated with residual post-PEA PH. Conclusions This is the first prospective study to describe an association of HbA1c-levels with pulmonary hemodynamics and exercise capacity in operable CTEPH patients. Our preliminary results indicate that in these patients impaired glucose metabolism as assessed by HbA1c is of clinical significance. However, HbA1c failed as a predictor of the hemodynamic outcome one-year post-PEA.
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de Perrot M, Thenganatt J, McRae K, Moric J, Mercier O, Pierre A, Mak S, Granton J. Pulmonary endarterectomy in severe chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2015; 34:369-75. [DOI: 10.1016/j.healun.2014.09.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 08/20/2014] [Accepted: 09/03/2014] [Indexed: 10/24/2022] Open
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Ogino H. Recent advances of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension including Japanese experiences. Gen Thorac Cardiovasc Surg 2013; 62:9-18. [DOI: 10.1007/s11748-013-0323-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Indexed: 11/25/2022]
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Predictors of postoperative outcome after pulmonary endarterectomy from a 14-year experience with 279 patients. Eur J Cardiothorac Surg 2011; 40:154-61. [DOI: 10.1016/j.ejcts.2010.10.043] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Revised: 10/20/2010] [Accepted: 10/26/2010] [Indexed: 12/18/2022] Open
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Stein E, Ramakrishna H, Augoustides JGT. Recent advances in chronic thromboembolic pulmonary hypertension. J Cardiothorac Vasc Anesth 2011; 25:744-8. [PMID: 21620730 DOI: 10.1053/j.jvca.2011.03.182] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Indexed: 12/20/2022]
Abstract
Surgical excellence in pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH) has begun to spread around the world. The perioperative mortality for this procedure is typically under 10%. The maximal benefit from PTE is derived in those patients who have a high proximal clot burden that is surgically accessible, as outlined by the Jamieson classification. Residual pulmonary hypertension after successful PTE is common and increasingly is managed with maintenance oral pulmonary vasodilator therapy such as endothelin antagonists, phosphodiesterase inhibitors, and/or prostaglandins. The role of pulmonary vasodilator therapy in CTEPH before PTE is limited and should not delay definitive surgical therapy. Although plain deep hypothermic circulatory arrest (DHCA) is the classic technique for CTEPH, alternatives such as DHCA with antegrade cerebral perfusion are feasible as well. Prolonged mechanical ventilation after PTE remains common in part because of reperfusion pulmonary edema. Careful perioperative management can reduce the incidence of this syndrome. Because ventilator-associated pneumonia is also a common complication after PTE, it represents a major opportunity for outcome improvement, particularly because there are multiple modalities for its prevention and prompt diagnosis.
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Affiliation(s)
- Erica Stein
- Department of Anesthesiology, Ohio State University, Columbus, OH, USA
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