Complete Pulmonary Artery Occlusion from Chronic Thromboembolic Disease: Outcomes Following Pulmonary Thromboendarterectomy Surgery

PurposeCharacterize patients with chronic thromboembolic pulmonary hypertension (CTEPH) with complete main pulmonary artery occlusion, and their response to pulmonary thromboendarterectomy (PTE).MethodsRetrospective review of a patient database at a PTE referral center. Two independent reviewers evaluated radiographic data including ventilation/perfusion (V/Q) scans and chest radiographs. Demographic data, operative findings, hemodynamic changes and clinical outcomes were collected. Patients were included if the V/Q scan revealed nonperfusion of an entire lung. Presence of contralateral filling defects on V/Q scan was also noted.ResultsOf 603 PTE patients operated between January 2009 and June 2013, 25 had complete main pulmonary artery occlusion; 13 patients had only unilateral disease and 12 had disease in the contralateral lung. Mean age was 41.8 years, 72% were female, and median time elapsed between PE or CTEPH diagnosis and surgery was 17 months. Average pre-operative pulmonary vascular resistance (PVR) was 508 dyne*sec/cm5. Patients with purely unilateral disease had an average pre-operative PVR of 349 dyne*sec/cm5; 10 of 13 were female (77%). Following surgery, average PVR for all twenty five patients decreased to 229 dyne*sec/cm5. Hospital mortality was 0%. On post-operative V/Q scan, 7 patients (28%) had significant (>75% estimated) reperfusion of the occluded lung, 10 patients (40%) had partial reperfusion (<75% estimated), and 8 patients (32%) had minimal or no reperfusion. Seven (87%) reperfusion failure patients were female, and 4 (50%) had contralateral chronic thromboembolic (CTE) disease, compared to 47.1% in patients who reperfused. A median of 24 months had elapsed between CTE diagnosis and surgery, compared to 15 months in patients who reperfused. Three of four patients whose pre-operative chest radiograph showed moderate ipsilateral volume loss failed to reperfuse that lung postoperatively.ConclusionPatients with main pulmonary artery occlusion from chronic thromboembolic disease appear to be at higher risk for reperfusion failure than what is reported in typical patients following PTE. Available data have been scarce in predicting patients at risk for this outcome. This study suggests that duration of main PA occlusion, female gender, and ipsilateral lung volume loss may be important. PurposeCharacterize patients with chronic thromboembolic pulmonary hypertension (CTEPH) with complete main pulmonary artery occlusion, and their response to pulmonary thromboendarterectomy (PTE). Characterize patients with chronic thromboembolic pulmonary hypertension (CTEPH) with complete main pulmonary artery occlusion, and their response to pulmonary thromboendarterectomy (PTE). MethodsRetrospective review of a patient database at a PTE referral center. Two independent reviewers evaluated radiographic data including ventilation/perfusion (V/Q) scans and chest radiographs. Demographic data, operative findings, hemodynamic changes and clinical outcomes were collected. Patients were included if the V/Q scan revealed nonperfusion of an entire lung. Presence of contralateral filling defects on V/Q scan was also noted. Retrospective review of a patient database at a PTE referral center. Two independent reviewers evaluated radiographic data including ventilation/perfusion (V/Q) scans and chest radiographs. Demographic data, operative findings, hemodynamic changes and clinical outcomes were collected. Patients were included if the V/Q scan revealed nonperfusion of an entire lung. Presence of contralateral filling defects on V/Q scan was also noted. ResultsOf 603 PTE patients operated between January 2009 and June 2013, 25 had complete main pulmonary artery occlusion; 13 patients had only unilateral disease and 12 had disease in the contralateral lung. Mean age was 41.8 years, 72% were female, and median time elapsed between PE or CTEPH diagnosis and surgery was 17 months. Average pre-operative pulmonary vascular resistance (PVR) was 508 dyne*sec/cm5. Patients with purely unilateral disease had an average pre-operative PVR of 349 dyne*sec/cm5; 10 of 13 were female (77%). Following surgery, average PVR for all twenty five patients decreased to 229 dyne*sec/cm5. Hospital mortality was 0%. On post-operative V/Q scan, 7 patients (28%) had significant (>75% estimated) reperfusion of the occluded lung, 10 patients (40%) had partial reperfusion (<75% estimated), and 8 patients (32%) had minimal or no reperfusion. Seven (87%) reperfusion failure patients were female, and 4 (50%) had contralateral chronic thromboembolic (CTE) disease, compared to 47.1% in patients who reperfused. A median of 24 months had elapsed between CTE diagnosis and surgery, compared to 15 months in patients who reperfused. Three of four patients whose pre-operative chest radiograph showed moderate ipsilateral volume loss failed to reperfuse that lung postoperatively. Of 603 PTE patients operated between January 2009 and June 2013, 25 had complete main pulmonary artery occlusion; 13 patients had only unilateral disease and 12 had disease in the contralateral lung. Mean age was 41.8 years, 72% were female, and median time elapsed between PE or CTEPH diagnosis and surgery was 17 months. Average pre-operative pulmonary vascular resistance (PVR) was 508 dyne*sec/cm5. Patients with purely unilateral disease had an average pre-operative PVR of 349 dyne*sec/cm5; 10 of 13 were female (77%). Following surgery, average PVR for all twenty five patients decreased to 229 dyne*sec/cm5. Hospital mortality was 0%. On post-operative V/Q scan, 7 patients (28%) had significant (>75% estimated) reperfusion of the occluded lung, 10 patients (40%) had partial reperfusion (<75% estimated), and 8 patients (32%) had minimal or no reperfusion. Seven (87%) reperfusion failure patients were female, and 4 (50%) had contralateral chronic thromboembolic (CTE) disease, compared to 47.1% in patients who reperfused. A median of 24 months had elapsed between CTE diagnosis and surgery, compared to 15 months in patients who reperfused. Three of four patients whose pre-operative chest radiograph showed moderate ipsilateral volume loss failed to reperfuse that lung postoperatively. ConclusionPatients with main pulmonary artery occlusion from chronic thromboembolic disease appear to be at higher risk for reperfusion failure than what is reported in typical patients following PTE. Available data have been scarce in predicting patients at risk for this outcome. This study suggests that duration of main PA occlusion, female gender, and ipsilateral lung volume loss may be important. Patients with main pulmonary artery occlusion from chronic thromboembolic disease appear to be at higher risk for reperfusion failure than what is reported in typical patients following PTE. Available data have been scarce in predicting patients at risk for this outcome. This study suggests that duration of main PA occlusion, female gender, and ipsilateral lung volume loss may be important.