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Quantifying the learning curve for pulmonary thromboendarterectomy.

Smita Sihag1,2, Bao Le3, Alison S Witkin4

  • 1Division of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit Street, Founders 7, Boston, Massachusetts, 02114, USA. sihags@mskcc.org.

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Summary

Pulmonary thromboendarterectomy (PTE) is a complex surgery for chronic thromboembolic pulmonary hypertension (CTEPH). Proficiency requires approximately 20 cases, with nearly 100 cases needed for efficient outcomes.

Keywords:
Learning curveOutcomesPulmonary thromboendarterectomy

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Area of Science:

  • Cardiothoracic Surgery
  • Pulmonary Hypertension Research
  • Surgical Education

Background:

  • Pulmonary thromboendarterectomy (PTE) is a critical treatment for chronic thromboembolic pulmonary hypertension (CTEPH).
  • PTE presents significant technical challenges for cardiothoracic surgeons.
  • Establishing a new PTE program offers a unique opportunity to delineate the learning curve for this procedure.

Purpose of the Study:

  • To define the learning curve for pulmonary thromboendarterectomy (PTE) in a newly established program.
  • To analyze the relationship between surgical experience and patient outcomes in PTE.
  • To identify key milestones for achieving proficiency and efficiency in PTE.

Main Methods:

  • A retrospective review of 134 consecutive PTE procedures performed between 1998 and 2016.
  • Outcomes were analyzed based on program experience, divided into terciles (T1-T3).
  • Statistical comparison used two-tailed t-tests for continuous variables and chi-squared tests for categorical variables.

Main Results:

  • The 30-day mortality rate was 3.7%, with average hospital stay of 12.6 days.
  • Significant reductions in systolic pulmonary artery pressure (sPAP) were observed (mean decrease 41.3 mmHg).
  • Cardiopulmonary bypass and circulatory arrest times decreased significantly with experience (p < 0.001), with inflection points at 22 and 95 cases.

Conclusions:

  • PTE is a challenging procedure requiring a multidisciplinary approach for optimal outcomes.
  • Surgical proficiency in PTE is estimated to require approximately 20 cases.
  • Nearly 100 cases are necessary to achieve efficient clearance of pulmonary artery obstructions.