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Pulmonary endarterectomy: the lancet first, tears for pills
M Morsolini1, M Boffini, G Paciocco
1Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, Division of Cardiac Surgery,Heart and Lung Transplantation and Pulmonary Endarterectomy Unit, University of Pavia, School of Medicine, Pavia, Italy - m.morsolini@smatteo.pv.it.
Insights
Chronic thromboembolic pulmonary hypertension (CTEPH) is a serious condition often treated with pulmonary endarterectomy (PEA). Early surgical candidate identification is crucial for optimal outcomes, as exercise capacity recovery lags behind hemodynamic improvement.
Area of Science:
- Cardiology
- Pulmonology
- Thoracic Surgery
Background:
- Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease caused by unresolved pulmonary emboli, leading to right heart failure and poor survival.
- Pulmonary endarterectomy (PEA) is the primary surgical treatment for CTEPH, but assessing lesion operability remains challenging and relies heavily on surgeon experience.
- Current diagnostic algorithms for CTEPH often still recommend ventilation/perfusion scans despite advancements in CT and MRI.
Purpose of the Study:
- To review the current understanding and management strategies for CTEPH.
- To highlight the importance of accurate operability assessment for PEA.
- To discuss the roles of medical therapy and lung transplantation in CTEPH management.
Main Methods:
- Review of current literature and clinical guidelines regarding CTEPH diagnosis and treatment.
- Discussion of diagnostic modalities including V/Q scans, CT, MRI, and selective pulmonary angiography.
- Analysis of treatment options: PEA, medical therapy, and lung transplantation.
Main Results:
- Selective pulmonary angiography is the gold standard for assessing CTEPH operability.
- Medical therapy is reserved for inoperable patients or those with persistent/recurrent disease post-PEA.
- Lung transplantation is an option for inoperable CTEPH or when PEA is contraindicated.
- Post-PEA outcomes are best predicted after surgery, with exercise capacity recovery lagging behind hemodynamic improvement.
Conclusions:
- Accurate assessment of surgical operability is critical for successful CTEPH management.
- Early identification of surgical candidates is essential to prevent physical deconditioning and optimize recovery.
- PEA remains the treatment of choice for operable CTEPH, with medical therapy and transplantation as alternative options for specific patient groups.
Abstract:
Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive disease due to the incomplete resolution of pulmonary emboli, leading to right heart failure, with a poor survival. Pulmonary endarterectomy (PEA) is the operation of choice for CTEPH. As there are no well-defined criteria to discriminate surgically accessible from inaccessible obstructive lesions, the operability assessment relies on the surgeon's experience. The recommended algorithms to perform a correct diagnosis of CTEPH still suggest the lung ventilation/perfusion scan, despite advances in computed tomography with 3-D reconstruction and magnetic resonance imaging. Selective pulmonary angiography is the gold standard to assess operability in CTEPH. Medical therapy should not be considered an alternative to PEA, as it should be reserved to patients with either peripheral disease, deemed inoperable by an experienced PEA surgeon, or persistent/recurrent pulmonary hypertension after PEA. Lung transplantation, when indicated, still represents a viable option for patients with either inoperable CTEPH or CTEPH with concomitant severe parenchymal lung disease that contraindicates PEA. The outcome of operable CTEPH is still best predicted after surgery. Remarkably, the recovery of exercise capacity is not as immediate as hemodynamic improvement, underlining the importance of early identification of surgical candidates before physical deconditioning.