Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension

Bilateral pulmonary thromboendarterectomy has been recognized as the first-choice therapeutic option for patients with chronic thromboembolic pulmonary hypertension. With careful patient selection, meticulous surgical technique and careful postoperative management the surgical procedure has proven potentially curative for these often severely incapacitated patients in whom prognosis is otherwise poor. By means of pulmonary angiography and multislice CT correct diagnosis is established and the crucial question of operability determined. In the presence of significant exertional dyspnea and/or elevation of pulmonary vascular resistance surgery is indicated when the thromboembolic obstructions are determined accessible to surgical removal. Suboptimal surgical results may be obtained in patients with solely peripheral location of lesions, i.e., beginning at the bronchopulmonary segmental arteries, and correct patient selection becomes crucial especially in advanced stages of disease of very high pulmonary vascular resistance and presence of right heart failure. The surgical techniques are standardized with use of median sternotomy with cardiopulmonary bypass, deep hypothermia and periods of circulatory arrest and consist of complete dissection of the intimal layer of the pulmonary branches containing the thromboembolic lesions as a true endarterectomy technique. The reported operative mortality for pulmonary thromboenclarterectomy differs in the literature between 4.5% and 23.5% and probably reflects not only the various experiences with this patient group but most likely also the disparate policies in patient selection. The authors' experience comprises 250 surgically treated patients with an operative mortality of 14.4%. The immediate hemodynamic and functional improvement of patients following successful thromboendarterectomy is excellent with further improvement during the first year. Pulmonary hypertension recurs over time in a few patients because of embolism, thrombosis or progression of reactive vasculopathy. However, the functional improvement and decrease of right ventricular afterload are persistent in the vast majority. Given the poor results of lung transplantation, this is not an alternative, and patients with chronic thromboembolic pulmonary hypertension should undergo thromboendarterectomy, preferably in the most early stage of their disease.