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Predictors of long-term survival after pulmonary endarterectomy
Ahmed K Awad1, Shawn Shah1, David Moros1
1Department of Thoracic & Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio.
Background:
Patients undergoing pulmonary thromboendarterectomy (PTE) have successful early to mid-term outcomes; however, they may not have consistent long-term follow-up. We aimed to examine the long-term survival and predictors of outcomes after PTE.
Methods:
Between 2008 and 2022, 308 patients with chronic thromboembolic pulmonary hypertension (CTEPH) underwent PTE at a tertiary institution. Baseline, operative, and postoperative variables were obtained from the institutional database. Survival follow-up was completed and analyzed with Kaplan-Meier estimates. The median duration of follow-up was 4.5 years, and multivariable analysis was performed for long-term survival.
Results:
Among the 308 patients, 50% had moderate or more right ventricular (RV) dysfunction, and preoperative mean pulmonary artery pressure (mPAP) was 43 mm Hg (15th-18th percentile, 31-55 mm Hg). The median circulatory arrest time during PTE was 35 minutes (15th-18th percentile, 23-49.7 minutes). Fifteen percent of the patients underwent concomitant tricuspid valve repair, while 5.5% had a reoperation. Operative mortality was 2.3%, and 7% of patients required extracorporeal membrane oxygenation after PTE. Postoperative mPAP was reduced to 26 mm Hg (15th-18th percentile, 19-35.5 mm Hg). Survival rates after PTE were 97% at 1 year, 90.4% at 5 years, and 79% at 8 years. The study cohort was stratified into 4 groups by preoperative RV dysfunction grade (normal, mild, moderate, and severe), and there was no significant difference in survival among the groups up to 5 years (P = .95). The prevalence of moderate or more RV dysfunction decreased for up to 3 years after surgery, then slowly rebounded. Preoperative higher oxygen requirement, pulmonary artery wedge pressure, and postoperative mPAP were independent predictors of long-term mortality. Interestingly, baseline RV function was not associated with long-term survival.
Conclusions:
The degree of preoperative RV dysfunction did not influence long-term survival after PTE. However, postoperative mPAP was associated with worse survival, suggesting the need for close follow-up of these patients to monitor compliance, pulmonary vascular or RV remodeling, and progression of CTEPH.
