Life expectancy after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a Swedish single-center study

Role of Surgical and Medical Management of Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review

Chronic thromboembolic pulmonary hypertension (CTEPH) is underdiagnosed and has recently surfaced as one of the leading triggers of severe pulmonary hypertension. This disease process is described by structural changes of pulmonary arteries such as fibrous stenosis, complete obliteration, or the presence of a resistant intraluminal thrombus, resulting in increased pulmonary resistance and eventually progressing to right-sided heart failure. Hence, this study aims to describe the current treatments for CTEPH and their efficacy in hemodynamic improvement and prevention of recurring thromboembolic episodes in patients. This systematic review promptly follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. On February 13, 2022, our team searched through the following databases: PubMed, ProQuest, and ScienceDirect. The following keywords were used across all databases: CTEPH AND Pulmonary Endarterectomy (PEA), CTEPH AND Balloon Pulmonary Angioplasty (BPA), and CTEPH AND Medical Therapy OR Anticoagulation therapy. Twenty-nine thousand eighty-nine articles on current management techniques (PEA, Balloon angioplasty, anticoagulants) were selected, analyzed, and reviewed with each other. We found 19 articles concerning PEA, 15 concerning BPA, and six regarding anticoagulants. Most papers showed high success rates and promising evidence of PEA and anticoagulants as a post-operative regimen. BPA was the least preferred but is still reputable in patients unfit for invasive techniques. CTEPH is a condition presenting with either fibrous stenosis, complete obliteration of the artery, or a clogged thrombus. Recent studies have shown three techniques that physicians have used to treat CTEPH: balloon-pulmonary angioplasty, PEA, and medical management with anticoagulants. PEA followed by anticoagulants is preferred to balloon pulmonary angioplasties. CTEPH is an ongoing topic in research; as it continues to be researched, we hope to see more management techniques available.

Quality of life and functional status after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: A Swedish single-center study

Little is known about long-term quality of life (QOL) and functional status after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH). We investigated QOL and functional status late after PEA. All patients who underwent PEA for CTEPH 1993-2020 at one Swedish center were included. Baseline characteristics and data from right heart catheterization, 6-min walk test, and Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) were obtained from patient charts and national registers. The RAND 36-Item Health Survey was sent by post, and Karnofsky Performance Status (KPS) was evaluated by telephone. A total of 110 patients were included. The survey was completed by 49/66 (74%) patients who were alive in 2020. In all domains except for bodily pain, QOL was slightly lower than that of an age-matched reference population. The KPS score was obtained from 42/49 (86%) patients; of these, 31 patients (74%) had a KPS score of ≥80% (able to carry on normal activity). All 42 patients were able to live at home and care for personal needs. The median postoperative CAMPHOR scores were: 4 for symptoms, 4 for activity, and 2.5 for QOL. We observed that QOL after PEA approached the expected QOL in a reference population and that CAMPHOR scores were comparable to those of a large UK cohort after PEA. Functional status improved when assessed late after PEA. Three-quarters of the study population were able to conduct normal activities at late follow-up. Our findings suggest that many patients enjoy satisfactory QOL and high functional status late after PEA.

Prognostic Relevance of Cardiopulmonary Exercise Testing for Patients with Chronic Thromboembolic Pulmonary Hypertension

Background: Following acute pulmonary embolism (PE), a relevant number of patients experience decreased exercise capacity which can be associated with disturbed pulmonary perfusion. Cardiopulmonary exercise testing (CPET) shows several patterns typical for disturbed pulmonary perfusion. Research question: We aimed to examine whether CPET can also provide prognostic information in chronic thromboembolic pulmonary hypertension (CTEPH). Study Design and Methods: We performed a multicenter retrospective chart review in Germany between 2002 and 2020. Patients with CTEPH were included if they had ≥6 months of follow-up and complete CPET and hemodynamic data. Symptom-limited CPET was performed using a cycle ergometer (ramp or Jones protocol). The association of anthropometric data, comorbidities, symptoms, lung function, and echocardiographic, hemodynamic, and CPET parameters with survival was examined. Mortality prediction models were calculated by Cox regression with backward selection. Results: 345 patients (1532 person-years) were included; 138 underwent surgical treatment (pulmonary endarterectomy or balloon pulmonary angioplasty) and 207 received only non-surgical treatment. During follow-up (median 3.5 years), 78 patients died. The death rate per 1000 person-years was 24.9 and 74.2 in the surgical and non-surgical groups, respectively (p < 0.001). In age- and sex-adjusted Cox regression analyses, CPET parameters including peak oxygen uptake (VO2peak, reflecting cardiopulmonary exercise capacity) were prognostic in the non-surgical group but not in the surgical group. In mortality prediction models, age, sex, VO2peak (% predicted), and carbon monoxide transfer coefficient (% predicted) showed significant prognostic relevance in both the overall cohort and the non-surgical group. In the non-surgical group, Kaplan−Meier analysis showed that patients with VO2peak below 53.4% predicted (threshold identified by receiver operating characteristic analysis) had increased mortality (p = 0.007). Interpretation: The additional measurement of cardiopulmonary exercise capacity by CPET allows a more precise prognostic evaluation in patients with CTEPH. CPET might therefore be helpful for risk-adapted treatment of CTEPH.

Chronic Thromboembolic Pulmonary Hypertension in Females: Clinical Features and Survival

Sparse data are available on the female-specific features of chronic thromboembolic pulmonary hypertension (CTEPH). We prospectively enrolled 160 consecutive female patients who were firstly diagnosed with CTEPH between 2013 and 2019 to explore their clinical phenotypes, treatment patterns, and long-term survival. The patients’ mean age was 54.7 ± 13.8 years, 70.6% provided a confirmed history of venous thromboembolism, 46 (28.8%) patients underwent pulmonary endarterectomy (PEA), 65 (40.6%) received balloon pulmonary angioplasty (BPA), and 49 (30.6%) were treated with medical therapy alone. The patients were followed for a median of 51 (34–70) months; three patients were lost to follow-up, and twenty-two patients died. The estimated survival rates at 1, 3, 5, and 7 years were 98.1% (95% CI 96.0–100), 96.9% (95% CI 94.2–99.6), 85.1% (95% CI 78.1–92.2), and 76.2% (95% CI 65.2–87.2), respectively. After adjusting for the confounders, the results of the multivariate Cox analysis showed that the presence of anemia (5.56, 95% CI 1.6–19.22) was associated with an increased risk of all-cause death, and compared with medical treatment, receiving PEA and BPA decreased the risk of death by 74% (0.26, 95% CI 0.07–0.97) and 86% (0.14, 95% CI 0.04–0.57), respectively. In conclusion, in the modern era of CTEPH treatment, invasive revascularization combined with targeted therapy display good clinical outcomes for females; anemia should be actively modified, which may lead to clinical improvements. (ClinicalTrials.gov Identifier: NCT05360992).

Impact of Sex, Race, and Socioeconomic Status on Survival after Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

OBJECTIVE

Pulmonary thromboendarterectomy (PTE) is a definitive treatment for chronic thromboembolic pulmonary hypertension (CTEPH). Demographic-based disparities in PTE outcomes have not been well studied.

METHODS

We reviewed all patients who underwent PTE for CTEPH between 2009 and 2019 at our institution, tracking demographic information including self-identified race, preoperative characteristics, and 2-year survival. Socioeconomic status (SES) was assessed using the zip code-linked Distressed Communities Index, a validated holistic measure of community well-being. Survival was estimated using Kaplan-Meier method and factors associated with mortality were estimated using Cox regression.

RESULTS

Of 235 PTE patients, 101 (42.9%) were white and 87 (37.0%) were black. White patients had a higher median age at surgery (57 vs. 51 years, P = 0.035) and a lower degree of economic distress (33.6 vs. 61.2 percentile, P < 0.001). Regarding sex, 106 (45.1%) patients were male and 129 (53.6%) were female. Male patients had a higher median age (59 vs. 50 years, P = 0.004), greater rates of dyslipidaemia (34% vs. 20.2%, P = 0.025), a lower ejection fraction (55% vs. 57%, P = 0.046), and longer cross-clamp (77 vs. 67.50 min, P = 0.004) and circulatory arrest times (42 vs. 37.50 min, P = 0.007). No difference was observed in unadjusted 2-year survival after PTE between patients stratified by race and sex (P = 0.35). After adjustment for clinically relevant variables, neither SES, sex, or race were associated with mortality in Cox proportional hazard analysis.

CONCLUSIONS

Sex, SES, and race were not associated with adverse outcomes after PTE in our single center experience.

Association of residual pulmonary hypertension with survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension

This study investigated whether residual pulmonary hypertension (PH), defined as early postoperative mean pulmonary artery pressure (mPAP) of ≥30 mmHg, after undergoing pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) was associated with long‐term survival. All patients who underwent PEA for CTEPH at two Scandinavian centers were included in this study. Baseline characteristics and vital statuses were obtained from patient charts and national health‐data registers. The patients were then categorized based on residual PH measured via right heart catheterization within 48 h after undergoing PEA. Crude and weighted flexible parametric survival models were used to estimate the association between residual PH and all‐cause mortality and to quantify absolute survival differences. From 1992 to 2020, 444 patients underwent surgery. We excluded 6 patients who died on the day of surgery and 12 patients whose early postoperative pulmonary hemodynamic data was unavailable. Of the total study population (n = 426), 174 (41%) and 252 (59%) patients had an early postoperative mPAP <30 and ≥30 mmHg, respectively. After weighting, there was a significant association between residual PH and all‐cause mortality (hazard ratio: 2.49; 95% confidence interval [CI]: 1.60–3.87), and the absolute survival difference between the groups at 10 and 20 years was –22% (95% CI: –32% to –12%) and–32% (95% CI: –47% to –18%), respectively. A strong and clinically relevant association of residual PH with long‐term survival after PEA for CTEPH was found. After accounting for differences in baseline characteristics, the absolute survival difference at long‐term follow‐up was clinically meaningful and imply careful surveillance to improve clinical outcomes in these patients. Early postoperative right heart catheter measurements of mPAP seem to be helpful for prognostication following PEA for CTEPH.

Non-invasive follow-up strategy after pulmonary endarterectomy for CTEPH

Background

The success of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is usually evaluated by performing a right heart catheterisation (RHC). Here, we investigate whether residual pulmonary hypertension (PH) can be sufficiently excluded without the need for a RHC, by making use of early post-operative haemodynamics, or N-terminal pro-brain natriuretic peptide (NT-proBNP), cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) 6 months after PEA.

Methods

In an observational analysis, residual PH after PEA measured by RHC was related to haemodynamic data from the post-operative intensive care unit time and data from a 6-month follow-up assessment including NT-proBNP, TTE and CPET. After dichotomisation and univariate analysis, sensitivity, specificity, positive predictive value, negative predictive value (NPV) and likelihood ratios were calculated.

Results

Thirty-six out of 92 included patients had residual PH 6 months after PEA (39%). Correlation between early post-operative and 6-month follow-up mean pulmonary artery pressure was moderate (Spearman rho 0.465, p<0.001). Early haemodynamics did not predict late success. NT-proBNP >300 ng·L⁻¹ had insufficient NPV (0.71) to exclude residual PH. Probability for PH on TTE had a moderate NPV (0.74) for residual PH. Peak oxygen consumption (V′_O2) <80% predicted had the highest sensitivity (0.85) and NPV (0.84) for residual PH.

Conclusions

CPET 6 months after PEA, and to a lesser extent TTE, can be used to exclude residual CTEPH, thereby safely reducing the number of patients needing to undergo re-RHC after PEA.

In approximately one-third to one-half of CTEPH patients, residual pulmonary hypertension after pulmonary endarterectomy can be excluded based on cardiopulmonary exercise testing or echocardiography, without the need for right heart catheterisationhttps://bit.ly/3pbj2Ge

Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review

BACKGROUND

Pulmonary thromboendarterectomy (PTE) is the gold standard treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, the results are poorly quantified outside a few registry reports and several individual centers.

METHODS

A systematic review was performed searching five electronic databases assessing the outcomes for adult patients undergoing PTE for CTEPH. All articles that reported mortality data were included. Primary outcome measures were early/inpatient mortality; secondary outcomes were survival, pulmonary haemodynamics, morbidity and functional status following PTE for CTEPH. Results were pooled via a meta-analysis of proportions and meta-regression.

RESULTS

A total of 5,717 studies were identified, yielding sixty-one relevant papers. Thirty-day mortality ranged from 0.8% to 24.4%, and on meta-analysis was 8.4% [95% confidence interval (CI): 7.2-9.6%]. Mortality was noted to decrease with increasing center volume of PTE cases (P<0.01). Residual pulmonary hypertension was reported in 8.2% to 44.5% of patients.

CONCLUSIONS

CTEPH is associated with acceptable short-term mortality and an improvement in pulmonary hemodynamics. With increasing volume of experience and ongoing developments over time peri-operative mortality continues to decrease.

Sex and survival following pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a Scandinavian observational cohort study

Studies have suggested sex-related survival differences in chronic thromboembolic pulmonary hypertension (CTEPH). Whether long-term prognosis differs between men and women following pulmonary endarterectomy for CTEPH remains unclear. We investigated sex-specific survival after pulmonary endarterectomy for CTEPH. We included all patients who underwent pulmonary endarterectomy for CTEPH at two Scandinavian centers and obtained baseline characteristics and vital statuses from patient charts and national health-data registers. Propensity scores and weighting were used to account for baseline differences. Flexible parametric survival models were employed to estimate the association between sex and all-cause mortality and the absolute survival differences. The expected survival in an age-, sex-, and year of surgery matched general population was obtained from the Human Mortality Database, and the relative survival was used to estimate cause-specific mortality. A total of 444 patients were included, comprising 260 (59%) men and 184 (41%) women. Unadjusted 30-day mortality was 4.2% in men versus 9.8% in women (p = 0.020). In weighted analyses, long-term survival did not differ significantly in women compared with men (hazard ratio: 1.36; 95% confidence interval: 0.89–2.06). Relative survival at 15 years conditional on 30-day survival was 94% (79%–107%) in men versus 75% (59%–88%) in women. In patients who underwent pulmonary endarterectomy for CTEPH, early mortality was higher in women compared with men. After adjustment for differences in baseline characteristics, female sex was not associated with long-term survival. However, relative survival analyses suggested that the observed survival in men was close to the expected survival in the matched general population, whereas survival in women deviated notably from the matched general population.

A model for estimating the health economic impact of earlier diagnosis of chronic thromboembolic pulmonary hypertension

Background

Diagnostic delay of chronic thromboembolic pulmonary hypertension (CTEPH) exceeds 1 year, contributing to higher mortality. Health economic consequences of late CTEPH diagnosis are unknown. We aimed to develop a model for quantifying the impact of diagnosing CTEPH earlier on survival, quality-adjusted life-years (QALYs) and healthcare costs.

Material and methods

A Markov model was developed to estimate lifelong outcomes, depending on the degree of delay. Data on survival and quality of life were obtained from published literature. Hospital costs were assessed from patient records (n=498) at the Amsterdam UMC – VUmc, which is a Dutch CTEPH referral center. Medication costs were based on a mix of standard medication regimens.

Results

For 63-year-old CTEPH patients with a 14-month diagnostic delay of CTEPH (median age and delay of patients in the European CTEPH Registry), lifelong healthcare costs were estimated at EUR 117 100 for a mix of treatment options. In a hypothetical scenario of maximal reduction of current delay, improved survival was estimated at a gain of 3.01 life-years and 2.04 QALYs. The associated cost increase was EUR 44 654, of which 87% was due to prolonged medication use. This accounts for an incremental cost–utility ratio of EUR 21 900/QALY.

Conclusion

Our constructed model based on the Dutch healthcare setting demonstrates a substantial health gain when CTEPH is diagnosed earlier. According to Dutch health economic standards, additional costs remain below the deemed acceptable limit of EUR 50 000/QALY for the particular disease burden. This model can be used for evaluating cost-effectiveness of diagnostic strategies aimed at reducing the diagnostic delay.

This constructed model based on the Dutch healthcare setting can be used for evaluating cost-effectiveness of diagnostic strategies aimed at reducing the diagnostic delay of chronic thromboembolic pulmonary hypertensionhttps://bit.ly/35yXPM3