Thromboendarterectomy for severe chronic thromboembolic pulmonary hypertension

Diagnostic evaluation and management of chronic thromboembolic pulmonary hypertension: a clinical practice guideline

BACKGROUND

Pulmonary embolism is a common condition. Some patients subsequently develop chronic thromboembolic pulmonary hypertension (CTEPH). Many care gaps exist in the diagnosis and management of CTEPH patients including lack of awareness, incomplete diagnostic assessment, and inconsistent use of surgical and medical therapies.

METHODS

A representative interdisciplinary panel of medical experts undertook a formal clinical practice guideline development process. A total of 20 key clinical issues were defined according to the patient population, intervention, comparator, outcome (PICO) approach. The panel performed an evidence-based, systematic, literature review, assessed and graded the relevant evidence, and made 26 recommendations.

RESULTS

Asymptomatic patients postpulmonary embolism should not be screened for CTEPH. In patients with pulmonary hypertension, the possibility of CTEPH should be routinely evaluated with initial ventilation/perfusion lung scanning, not computed tomography angiography. Pulmonary endarterectomy surgery is the treatment of choice in patients with surgically accessible CTEPH, and may also be effective in CTEPH patients with disease in more 'distal' pulmonary arteries. The anatomical extent of CTEPH for surgical pulmonary endarterectomy is best assessed by contrast pulmonary angiography, although positive computed tomography angiography may be acceptable. Novel medications indicated for the treatment of pulmonary hypertension may be effective for selected CTEPH patients.

CONCLUSIONS

The present guideline requires formal dissemination to relevant target user groups, the development of tools for implementation into routine clinical practice and formal evaluation of the impact of the guideline on the quality of care of CTEPH patients. Moreover, the guideline will be updated periodically to reflect new evidence or clinical approaches.

Improvement of Tricuspid Regurgitation after Pulmonary Thromboendarterectomy

Chronic thromboembolic pulmonary hypertension causes right ventricular dilation with various degrees of tricuspid regurgitation, leading to right heart failure. Pulmonary thromboendarterectomy can substantially improve pulmonary hemodynamics and right ventricular dilation. The aim of this study was to determine whether the reduction of tricuspid regurgitation persists during follow-up. We studied 26 patients undergoing pulmonary thromboendarterectomy without repair of tricuspid regurgitation; 24 were followed up for 7 to 59 months after surgery (mean, 33 months). Echocardiographic and right heart catheterization data were obtained before and early after surgery. Severity of tricuspid regurgitation and tricuspid pressure gradient were evaluated at follow-up. Two patients died early after surgery, but none died during follow-up. Pulmonary thromboendarterectomy substantially improved pulmonary hemodynamics and right ventricular dilation. Tricuspid regurgitation graded severe in 5 patients and moderate in another 5, improved to trivial or mild postoperatively. The decreases in tricuspid pressure gradient and regurgitation early after surgery persisted during follow-up.