Dynamic risk stratification of patient long-term outcome after pulmonary endarterectomy: results from the UK national cohort
File(s)
Author(s)
Type
Journal Article
Abstract
Background—Chronic thromboembolic pulmonary hypertension results from incomplete resolution of pulmonary emboli. Pulmonary endarterectomy (PEA) is potentially curative, but residual pulmonary hypertension 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 pulmonary hypertension post-PEA.
Methods and Results—Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require 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 for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s−1·cm−5 at reassessment correlated with worse long-term survival.
Conclusions—Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery.
Methods and Results—Eight hundred eighty consecutive patients (mean age, 57 years) underwent PEA for chronic thromboembolic pulmonary hypertension. Patients routinely underwent detailed reassessment with right heart catheterization and noninvasive testing at 3 to 6 months and annually thereafter with discharge if they were clinically stable at 3 to 5 years and did not require 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 for the whole cohort and 91% and 90% at 1 and 3 years for the recent half of the cohort. The majority of patient deaths after the perioperative period were not attributable to right ventricular failure (chronic thromboembolic pulmonary hypertension). At reassessment, a mean pulmonary artery pressure of ≥30 mm Hg correlated with the initiation of pulmonary vasodilator therapy post-PEA. A mean pulmonary artery pressure of ≥38 mm Hg and pulmonary vascular resistance ≥425 dynes·s−1·cm−5 at reassessment correlated with worse long-term survival.
Conclusions—Our data confirm excellent long-term survival and maintenance of good functional status post-PEA. Hemodynamic assessment 3 to 6 months and 12 months post-PEA allows stratification of patients at higher risk of dying of chronic thromboembolic pulmonary hypertension and identifies a level of residual pulmonary hypertension that may guide the long-term management of patients postsurgery.
Date Issued
2016-04-06
Date Acceptance
2016-03-18
Citation
Circulation, 2016, 133 (18), pp.1761-1771
ISSN
0009-7322
Publisher
American Heart Association
Start Page
1761
End Page
1771
Journal / Book Title
Circulation
Volume
133
Issue
18
Copyright Statement
© 2016 American Heart Association, Inc.
Identifier
PII: CIRCULATIONAHA.115.019470
Subjects
Science & Technology
Life Sciences & Biomedicine
Cardiac & Cardiovascular Systems
Peripheral Vascular Disease
Cardiovascular System & Cardiology
endarterectomy
hypertension
pulmonary
pulmonary embolism
survival
INTERNATIONAL PROSPECTIVE REGISTRY
SINGLE-CENTER EXPERIENCE
THROMBOEMBOLIC DISEASE
SURGICAL-MANAGEMENT
HYPERTENSION CTEPH
CIRCULATORY ARREST
FOLLOW-UP
THROMBOENDARTERECTOMY
SURGERY
SURVIVAL
endarterectomy
hypertension, pulmonary
pulmonary embolism
survival
Adolescent
Adult
Aged
Aged, 80 and over
Cohort Studies
Endarterectomy
Female
Follow-Up Studies
Humans
Hypertension, Pulmonary
Male
Middle Aged
Prospective Studies
Risk Assessment
Survival Rate
Time Factors
Treatment Outcome
United Kingdom
Young Adult
Humans
Hypertension, Pulmonary
Treatment Outcome
Endarterectomy
Survival Rate
Risk Assessment
Cohort Studies
Follow-Up Studies
Prospective Studies
Time Factors
Adolescent
Adult
Aged
Aged, 80 and over
Middle Aged
Female
Male
Young Adult
United Kingdom
Cardiovascular System & Hematology
1102 Cardiorespiratory Medicine and Haematology
1103 Clinical Sciences
1117 Public Health and Health Services
Publication Status
Published
Date Publish Online
2016-04-06