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Pulmonary Thromboendarterectomy for Chronic Thromboembolic Pulmonary Hypertension

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posted on 22.04.2020, 20:22 by Guillermo Gutierrez, Franco Gutierrez, Gustavo Bastianelli, Guillermo Vaccarino

Introduction
Chronic thromboembolic pulmonary hypertension is a progressive disease with poor prognosis if left untreated. The reported incidence is five cases per million per year, however that number could be below the actual incidence due to its low symptomatology and resultant underdiagnosis. Its pathogenesis is that of recurrent pulmonary thromboembolism with incomplete resolution of the thrombi. Pulmonary artery obstruction causes increased pulmonary vascular resistance and pulmonary arterial pressure, increasing afterload leading to right ventricular failure.

The management of this disease has undergone many changes in the last 10 years. The mortality in patients without adequate treatment is 90% at three years. However, it is a potentially curable disease by performing pulmonary thromboendarterectomy, the procedure of choice to achieve relief of pulmonary artery obstruction. It is a technically demanding procedure that requires specialized training and sophisticated intensive care in the postoperative period. Candidates for this surgery are selected based on right heart catheterization, pulmonary angiography, and pulmonary angiotomography, not excluding patients based on the severity of pulmonary resistance, since with a correct endarterectomy, cardiopulmonary function can be restored to normal or almost normal, even in patients with advanced disease.

The results of pulmonary endarterectomy have been improving substantially in the last 10 years in experienced centers to the point that it can be performed with similar risks to any other complex cardiac surgery. The operation offers both clinical and physiological improvement, returning patients to functional class I or II after surgery, with excellent long-term results and 5-year survival greater than 90%.

Conclusion
Surgery is currently the only definitive therapy with proven curative potential in chronic pulmonary hypertension with thromboembolic origin. Decreases in pulmonary artery pressure and pulmonary vascular resistance are immediate and result in significant improvement in symptoms and survival. The use of ECMO is beneficial in the presence of the most severe complications during the postoperative period after pulmonary endarterectomy. Therefore, pulmonary thromboendarterectomy should be considered in all patients with chronic thromboembolic pulmonary hypertension, performed in experienced centers by expert surgeons

References

  1. Opitz I, de Perrot M. Technique of pulmonary thromboendarterectomy. Op Tech Cardiovasc Surg. 2012;17(3):1522-2942.
  2. Madani M, Mayer E, Fadel E, Jenkins DP. Pulmonary endarterectomy; patient selection, technical challenges, and outcomes. Ann Am Thorac Soc. 2016 Jul;13(3):240-247.
  3. Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. J Cardiothorac Vasc Anesth. 2019 Nov;33(11):3110-3126.
  4. Sihag S, Le B, Witkin AS, Rodriguez-Lopez JM, Villavicencio MA, et al. Quantifying the learning curve for pulmonary thromboendarterectomy. J Cardiothorac Surg. 2017 Dec 28;12(1):121.
  5. López Gude MJ, Pérez de la Sota E, Forteza Gil A, Centeno Rodríguez J, Eixerés A, Velázquez MT, et al. Pulmonary thromboendarterectomy in 106 patients with chronic thromboembolic pulmonary hypertension. Arch Bronconeumol. 2015;51(10):502–508.

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