Dynamic Risk Stratification of Patient Long-Term Outcome After Pulmonary Endarterectomy

Abstract

Background—Chronic thromboembolic pulmonary hypertension (CTEPH) results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual PH following surgery is common and its impact on long-term outcome is poorly understood. We wanted to identify factors correlated with poor long-term outcome after surgery and specifically define clinically relevant residual PH post-PEA. Methods and Results—880 consecutive patients (mean age 57 years) underwent PEA for CTEPH. Patients routinely underwent detailed re-assessment with right heart catheterisation and non-invasive testing at 3-6 months and annually thereafter with discharge if clinically stable at 3- 5 years and not requiring pulmonary vasodilator therapy. Cox regressions were used for survival (time-to-event) analyses. Overall survival was 86%, 84%, 79% and 72% at 1, 3, 5 and 10 years time-to-event) analyses. Overall survival was 86%, 84%, 79% and 72% at 1, 3, 5 and n 10 years for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The for the whole cohort and 91% and 90% at 1 and 3 t half of the cohort. The o majority of patient deaths after the peri-operative period were not due to right ventricular failure ajority of patient deaths after the peri-operative period w re not due to right ventricular failure (CTEPH). At reassessment a mean pulmonary artery pressure (mPAP) ? 30 mmHg correlated CTE EPH). At rea sessment a mean pulmonary ar ass rter ry pressure (mPAP) 30 mmHg correlated w h with pulmona yary vas with pulm nary vasodilator therapy initiation post-PEA. An mPAP a odilator thera apy initiation p stt-P A. An mPAP ? 38 mmHg and pulmonary po PEA 38 mmHg and pulmonary vasc vascular resistance cular resistan enc ? 425 dy e/sec/cm at reassessmm- 425 dyne/sec/cm 2 yne -5 at reasses ment corre ea ssment correlated with worse long elate ed with h wor e long-term rse g-tterm m survival. urv vival. Conclusions— Conclusions—Our data confirm excellent long-term llent long-term survival and maintenance of good intenance of good functional status post-PEA. Haemodynamic assessment 3-6 and/or 12 months post-PEA allows stratification of patients at higher risk of dying from CTEPH and identifies a level of residual pulmonary hypertension which may guide the long-term management of patients post-surgery. Key