Angiographic predictors of hemodynamic improvement after pulmonary endarterectomy

Postoperative outcome after pulmonary endarterectomy (PEA) for CTEPH (chronic thromboembolic pulmonary hypertension) is difficult to predict. We analyzed specific angiographic findings to predict the success of PEA.

Pulmonary angiograms were reviewed retrospectively in 90 patients with CTEPH who underwent PEA. The proximal 2 cm of a segmental artery were classified into the following: A, occlusion; B, pouch or membrane; or C, delayed perfusion. The number of involved segments was recorded. Logistic regression analysis was used to predict mortality and hemodynamic improvement after PEA.

An average of 15.7 +/- 2.9 segments were involved angiographically per patient (A, 7.6 +/- 2.9; B, 4.6 +/- 3.1; C, 3.5 +/- 2.7). No variable was significant in multivariate analysis to predict early mortality (n = 6, 6.7%). More than 50% reduction in postoperative pulmonary vascular resistance (PVR) at 24 hours (n = 71) could be predicted by higher PVR, more involved segments, male gender, and higher diastolic pulmonary arterial pressure with an area under the curve in the receiver operating characteristics curve of 0.9021. The PVR less than 400 dynes x sec x cm(-5) at 48 hours after PEA (n = 81) could be predicted by type B lesions, duration of symptoms, more involved segments, and serum creatinine level with area under the curve in the receiver operating characteristics curve of 0.9160. The PVR at 48 hours after PEA could be predicted by serum creatinine level, involved segments, PVR, and gender (P < 0.001, R = 0.551, R(2) = 0.304).

Angiographic criteria can predict the success of PEA. Segments with obstruction but preserved peripheral perfusion seem to have more impact than occluded segments on hemodynamic improvement.