Experience with pulmonary endarterectomy: Lessons learned across 17 years.

BACKGROUND: Pulmonary endarterectomy is potential curative therapy for chronic thromboembolic pulmonary hypertension patients. Here, we present our experience with pulmonary endarterectomy spanning 17 years and detail our management strategy. METHODS: This is a single-centre retrospective study conducted on chronic thromboembolic pulmonary hypertension patients who underwent pulmonary endarterectomy at our centre across 17 years. RESULTS: Between 2004 and 2020, 591 patients underwent pulmonary endarterectomy. Amongst them 429 (72.4%) were males with a male to female ratio of 2.6:1, the median age was 38 (range, 14-73) years. The median length of hospital stay was 11 days (IQR, 8-16). Extra corporeal membranous oxygenation was used in 82 (13.9%) patients during/after surgery, out of whom 28 (34.1%) survived. There were 70 (11.8%) in-hospital deaths. Female gender (p < 0.01), pulmonary artery systolic pressure >100 mmHg (p < 0.05) and use of extra corporeal membrane oxygenation (p < 0.001) were significant risk factors for in-hospital mortality. The mortality in the first period (2004-2012) was 15.7% which reduced to 9.1% in the later period (2013-2020). The reduction in mortality rate was 42% (p < 0.05). Following pulmonary endarterectomy, there was a significant reduction in pulmonary artery systolic pressure (86.68 ± 24.38 vs. 39.71 ± 13.13 mmHg; p < 0.001) and improvement in median walk distance as measured by 6-min walk test on follow-up (300 vs. 450 meters; p < 0.001). The median duration of follow-up was 8 months (inter-quartile range: 2-24). CONCLUSIONS: pulmonary endarterectomy has a learning curve, high pulmonary vascular resistance alone is not a contraindication for surgery. Patients following surgery have improved survival and quality of life.

Management of intrapulmonary hemorrhage in patients undergoing pulmonary thrombo-endarterectomy.

Massive pulmonary hemorrhage during pulmonary thromboendarterectomy (PTE) can be managed by a conservative approach with mechanical ventilatory support, positive end-expiratory pressure, lung isolation, reversal of heparin, and correct of coagulopathy. We present three challenging cases that developed intrapulmonary hemorrhage during/after PTE and managed successfully. The first patient had bleeding from the bronchial artery and right internal mammary collaterals, which was managed by coil-embolization. The second patient had a breach in the blood airway barrier in the right upper lobar segment of the lung, and the repair was done using a surgical absorbable hemostat. The third patient developed reperfusion injury, he was instituted on veno-venous extracorporeal membranous oxygenation, a week later, the patient recovered completely. An algorithm was adopted and modified to our requirements; all the 3 challenging intrapulmonary hemorrhage cases were successfully managed. This algorithm can be used for satisfactory outcomes in patients who suffer intrapulmonary hemorrhage during PTE.