Chronic thromboembolic pulmonary hypertension: A comprehensive review of pathogenesis, diagnosis, and treatment strategies.

Chronic thromboembolic pulmonary hypertension (CTEPH) is part of group 4 of the pulmonary hypertension (PH) classification and generally affects more than a third of patients referred to PH centers. It is a three-compartment disease involving proximal (lobar-to-segmental) and distal (subsegmental) pulmonary arteries that are obstructed by persistent fibrothrombotic material, and precapillary pulmonary arteries that can be affected as in pulmonary arterial hypertension. It is a rare complication of pulmonary embolism (PE), with an incidence of around 3% in PE survivors. The observed incidence of CTEPH in the general population is around six cases per million but could be three times higher than this, as estimated from PE incidence. However, a previous venous thromboembolic episode is not always documented. With advances in multimodality imaging and therapeutic management, survival for CTEPH has improved for both operable and inoperable patients. Advanced imaging with pulmonary angiography helps distinguish proximal from distal obstructive disease. However, right heart catheterization is of utmost importance to establish the diagnosis and hemodynamic severity of PH. The therapeutic strategy relies on a stepwise approach, starting with an operability assessment. Pulmonary endarterectomy (PEA), also known as pulmonary thromboendarterectomy, is the first-line treatment for operable patients. Growing experience and advances in surgical technique have enabled expansion of the distal limits of PEA and significant improvements in perioperative and mid- to long-term mortality. In patients who are inoperable or who have persistent/recurrent PH after PEA, medical therapy and/or balloon pulmonary angioplasty (BPA) are effective treatment options with favorable outcomes that are increasingly used. All treatment decisions should be made with a multidisciplinary team that includes a PEA surgeon, a BPA expert, and a chest radiologist.

Evolución y pronóstico de la insuficiencia tricuspídea moderada-grave tras tromboendarterectomía pulmonar o angioplastia de arterias pulmonares / Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty

Introducción y objetivos: No está definido el abordaje de la insuficiencia tricuspídea (IT) funcional moderada-grave en los pacientes con hipertensión pulmonar tromboembólica crónica tras la tromboendarterectomía pulmonar (TEA) o angioplastia con balón de las arterias pulmonares (ABAP). El objetivo de este estudio es analizar la evolución y los predictores de IT residual tras el procedimiento, así como su impacto pronóstico. Métodos: Estudio observacional unicéntrico. Se incluyó a 72 pacientes sometidos a TEA y 20 que completaron el programa de ABAP con diagnóstico de hipertensión pulmonar tromboembólica crónica y presentaban IT moderada-grave antes del procedimiento intervencionista. Resultados: La prevalencia de IT moderada-grave tras el procedimiento fue del 29%, sin diferencias entre los tratados con TEA o ABAP (el 30,6 frente al 25%; p=0,78). En el grupo con IT persistente se hallaron mayores presión arterial pulmonar media (40,2± 1,9 frente a 28,5±1,3mmHg; p<0,001), resistencia vascular pulmonar (472 [347-710] frente a 282 [196-408] dyn·s/cm5; p <0,001) y área de la aurícula derecha (23,0 [21-31] frente a 16,0 [14,0-20,0]; p <0,001) tras el procedimiento comparado con el de pacientes con IT ausente-ligera. La resistencia vascular pulmonar> 400dyn.s/cm5 y el área de la aurícula derecha> 22 cm2 tras el procedimiento se asociaron de manera independiente con la persistencia de la IT, pero no se identificaron predictores antes de la intervención. La IT moderada-grave residual y la presión pulmonar media> 30mmHg se asociaron con mayor mortalidad en 3 años de seguimiento. Conclusiones: La IT moderada-grave residual posterior a TEA o ABAP se asoció con la persistencia de una mayor poscarga y un persistente remodelado desfavorable de las cámaras cardiacas derechas tras el procedimiento. La IT moderada-grave y la hipertensión pulmonar residual se asociaron con un peor pronóstico a 3 años. (AU)

Introduction and objectives: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. Methods: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. Results: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. Conclusions: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis. (AU)

Outcome of moderate-severe tricuspid regurgitation after pulmonary endarterectomy or balloon pulmonary angioplasty.

INTRODUCTION AND OBJECTIVES: The management of persistent moderate-severe tricuspid regurgitation (TR) in patients with chronic thromboembolic pulmonary hypertension after treatment with pulmonary endarterectomy (PEA) or balloon pulmonary angioplasty (BPA) is not well defined. This study aimed to analyze the progression and predictors of significant persistent postintervention TR and its prognostic impact. METHODS: This single-center observational study included 72 patients undergoing PEA and 20 who completed a BPA program with a previous diagnosis of chronic thromboembolic pulmonary hypertension and moderate-to-severe TR. RESULTS: The postintervention prevalence of moderate-to-severe TR was 29%, with no difference between the PEA- or BPA-treated groups (30.6% vs 25% P=.78). Compared with patients with absent-mild postprocedure TR, those with persistent TR had higher mean pulmonary arterial pressure (40.2±1.9 vs 28.5±1.3mmHg P <.001), pulmonary vascular resistance (472 [347-710] vs 282 [196-408] dyn.s/cm5; P <.001), and right atrial area (23.0 [21-31] vs 16.0 [14.0-20.0] P <.001). The variables independently associated with persistent TR were pulmonary vascular resistance> 400 dyn.s/cm5 and postprocedure right atrial area> 22cm2. No preintervention predictors were identified. The variables associated with increased 3-year mortality were residual TR and mean pulmonary arterial pressure> 30mmHg. CONCLUSIONS: Residual moderate-to-severe TR following PEA-PBA was associated with persistently high afterload and unfavorable postintervention right chamber remodeling. Moderate-to-severe TR and residual pulmonary hypertension were associated with a worse 3-year prognosis.

Clinical and hemodynamic outcomes and mortality risk factors in patients undergoing pulmonary thromboendarterectomy / Resultados clínicos y hemodinámicos y factores de riesgo de mortalidad en pacientes sometidos a tromboendarterectomía pulmonar

Abstract Background: Pulmonary thromboendarterectomy is the current treatment of choice in patients with chronic thromboembolic pulmonary hypertension. The objective of the present study was to analyze the clinical and hemodynamic outcomes and the risk factors for mortality in a cardiovascular center in Colombia. Methods: Cohort study, conducted between 2001 and 2019. All operated patients were included in the study. Risk factors associated with mortality were established by means of a multivariate regression using the COX method and survival was established using the Kaplan-Meier method. p < 0.05 was considered statistically significant. Results: Seventy-three patients were operated. Median age was 51 years, 55% of females, 79% had functional Class III and IV. The mean pulmonary arterial pressure was 50 mmHg and 640 dyn.s.cm−5 for pulmonary vascular resistance (PVR). After the intervention, there was a decrease in mean pulmonary artery pressure (p ≤ 0.001) and in PVR (p = 0.357); 21% had evidence of residual pulmonary hypertension. Only 8% and 6% continued with functional Class III and IV at 6 and 12 months, respectively. There were 15 deaths (19.1%; 12% at 30 days). The factors associated with mortality were the diastolic diameter of the right ventricle measured postoperatively (hazard ratio [HR] 10.88 95% confidence interval [CI] 1.97-62, p = 0.007), time of invasive mechanical ventilation (HR 1.06 95% CI 1.02-1.09 p = 0.004), and the presence of complications during the surgical procedure (HR 5.62 95% CI 1.94-16.22 p = 0.001). Conclusions: Pulmonary thromboendarterectomy is associated with excellent clinical and hemodynamic outcomes. The mortality risk factors found are not those usually described in the literature.

Resumen Antecedentes: La tromboendarterectomía pulmonar es el tratamiento de elección actual en pacientes con hipertensión pulmonar tromboembólica crónica. El objetivo del presente estudio fue analizar los resultados clínicos y hemodinámicos y los factores de riesgo de mortalidad en un centro cardiovascular de Colombia. Métodos: Estudio de cohorte entre 2001 y 2019. Se incluyeron todos los pacientes operados. Los factores de riesgo asociados a la mortalidad se establecieron mediante una regresión multivariante mediante el método COX y la supervivencia se estableció mediante el método de Kaplan-Meier. Los valores de p < 0.05 se consideraron estadísticamente significativos. Resultados: se operaron 73 pacientes. La mediana de edad fue de 51 años, 55% mujeres, 79% tenían clase funcional III y IV. La presión arterial pulmonar media fue de 50 mmHg y 640 dyn.s.cm−5 para la resistencia vascular pulmonar. Después de la intervención, hubo una disminución en la presión arterial pulmonar media (p ≤ 0.001) y en la resistencia vascular pulmonar (p = 0.357). El 21% tenía evidencia de hipertensión pulmonar residual. Solo el 8% y el 6% continuaron con clase funcional III y IV a los 6 y 12 meses respectivamente. Hubo 15 muertes (19.1%; 12% a los 30 días). Los factores asociados con la mortalidad fueron el diámetro diastólico del ventrículo derecho medido en el postoperatorio (HR 10.88 IC 95% 1.97-62, p = 0.007), el tiempo de ventilación mecánica invasiva (HR 1.06 IC 95% 1.02-1.09 p = 0.004) y el presencia de complicaciones durante el procedimiento quirúrgico (HR 5.62 IC 95% 1.94-16.22 p = 0.001). Conclusiones: La tromboendartectomía pulmonar se asocia con excelentes resultados clínicos y hemodinámicos. Los factores de riesgo de mortalidad encontrados no son los habitualmente descritos en la literatura.

Chronic thromboembolic pulmonary hypertension: Initial experience of patients undergoing pulmonary thromboendarterectomy.

INTRODUCTION AND OBJECTIVES: Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS: Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS: 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5,2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n=3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION: Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.

Chronic thromboembolic pulmonary hypertension: initial experience of patients undergoing pulmonary thromboendarterectomy. / Hipertensão pulmonar tromboembólica crónica: experiência inicial de doentes submetidos a tromboendarterectomia pulmonar.

INTRODUCTION AND OBJECTIVES: Pulmonary endarterectomy (PEA) is a potentially curative procedure in patients with chronic thromboembolic pulmonary hypertension (CTEPH). This study reports the initial experience of a Portuguese PH center with patients undergoing PEA at an international surgical reference center. METHODS: Prospective observational study of consecutive CTEPH patients followed at a national PH center, who underwent PEA at an international surgical reference center between October 2015 and March 2019. Clinical, functional, laboratory, imaging and hemodynamic parameters were obtained in the 12 months preceding the surgery and repeated between four and six months after PEA. RESULTS: 27 consecutive patients (59% female) with a median age of 60 (49-71) years underwent PEA. During a median follow-up of 34 (21-48) months, there was an improvement in functional class in all patients, with only one cardiac death. From a hemodynamic perspective, there was a reduction in mean pulmonary artery pressure from 48 (42-59) mmHg to 26 (22-38) mmHg, an increase in cardiac output from 3.3 (2.9-4.0) L/min to 4.9 (4.2-5.5) L/min and a reduction in pulmonary vascular resistance from 12.1 (7.2-15.5) uW to 3.5 (2.6-5, 2) uW. During the follow-up, 44% (n=12) of patients had no PH criteria, 44% (n=12) had residual PH and 11% (n = 3) had PH recurrence. There was a reduction of N-terminal pro-B-type natriureticpeptide from 868 (212-1730) pg/mL to 171 (98-382) pg/mL. Rright ventricular systolic function parameters revealed an improvement in longitudinal systolic excursion and peak velocity of the plane of the tricuspid ring from 14 (13-14) mm and 9 (8-10) cm/s to 17 (16-18) mm and 13 (11-15) cm/s, respectively. Of the 26 patients with preoperative right ventricular dysfunction, 85% (n=22) recovered. The proportion of patients on specific vasodilator therapy decreased from 93% to 44% (p<0.001) and the proportion of those requiring oxygen therapy decreased from 52% to 26% (p=0.003). The six-minute walk test distance increased by about 25% compared to the baseline and only eight patients had significant desaturation during the test. CONCLUSION: Pulmonary endarterectomy performed at an experienced high-volume center is a safe procedure with a very favorable medium-term impact on functional, hemodynamic and right ventricular function parameters in CTEPH patients with operable disease. It is possible for PH centers without PEA differentiation to refer patients safely and effectively to an international surgical center in which air transport is necessary.

Pulmonary thromboendarterectomy in Portugal: Initial experience.

INTRODUCTION: Surgical treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is challenging. Most Portuguese patients with CTEPH have been referred to foreign institutions for treatment, with significant social and economic costs. To meet this emerging need, the cardiothoracic surgery department of Hospital de Santa Marta, Lisbon, has developed a dedicated program for pulmonary thromboendarterectomy (PTE). We hereby present the results for the first 19 patients treated. METHODS: We conducted a retrospective analysis of all 19 patients who underwent PTE at Hospital de Santa Marta between 2008 and April 2019. RESULTS: Since 2008, a total of 19 patients have undergone PTE in our department. The procedure was performed with good outcomes in both survival and functional recovery. At the very beginning of the series two patients died perioperatively, before all the team underwent formal training at the Royal Papworth Hospital, UK, with no early deaths since. Postoperative complications were similar to other published series. During 11 years of follow-up, there were three late deaths, all in patients with residual pulmonary arterial hypertension. At the latest follow-up (October 2019), all surviving patients showed significant functional recovery, all in NYHA class I or II, with only one patient on vasodilator therapy with sildenafil (the first in the series, operated in 2008). CONCLUSIONS: PTE is a demanding procedure, in which outcomes are related to volume and accumulated experience, however it can be performed safely and with reproducible results by a properly prepared dedicated team with a well-controlled learning curve. More patients and multidisciplinary experience will be needed to further improve and streamline results.

Hipertensión pulmonar crónica tromboembólica tromboendarterectomía pulmonar / Chronic thromboembolic pulmonary hypertension

A nivel mundial, la tercera causa de muerte por causa cardiovascular es el Tromboembolismo Pulmonar (TEP), después del Infarto agudo de Miocardio y el Accidente cerebrovascular, con una incidencia anual estimada de 40 casos por cada 100.000 habitantes. Se comunica el caso clínico de un paciente de 44 años con diagnóstico de TEP recurrente con Hipertensión pulmonar tromboembólica crónica (CTPH) que fue sometido a tromboendarterectomía pulmonar bilateral (PTE) bajo paro circulatorio con hipotermia profunda. Se informa de los resultados de los medios de diagnóstico y del tratamiento quirúrgico mediante la tromboendarterectomía. Se discute el tema en el contexto de la experiencia internacional y nacional.

Cuidado de enfermería postoperación de Tromboendarterectomia Pulmonar Bilateral. Estudio de caso fundamentado en los principios de Henderson / Nursing care after Bilateral Pulmonary Thromboendarterectomy. Case study based on Henderson's principles / Cuidados de enfermagem após tromboendarterectomia pulmonar bilateral. Estudo de caso baseado nos princípios de Henderson

Resumen Introducción La tromboembolia pulmonar (TEP) es un padecimiento que se presenta con frecuencia de manera silenciosa, el 50 % o más de los casos no se diagnostica. Se define como la oclusión total o parcial de la circulación pulmonar, ocasionada por un coágulo sanguíneo proveniente de la circulación venosa sistémica, incluidas las cavidades derechas y que, de acuerdo a su magnitud, puede o no originar síntomas. Está considerada como una urgencia cardiovascular y constituye una de las principales causas de morbimortalidad en pacientes hospitalizados. Objetivo Desarrollar un Estudio de caso basado en el Proceso de Atención de Enfermería en la persona postoperada de Tromboendarterectomía Pulmonar Bilateral en Unidad de cuidados intensivos postquirúrgica de un Instituto Nacional de Tercer Nivel de la Ciudad de México. Método Estudio de caso basado en las etapas del proceso enfermero, se utilizó una Guía de valoración de las 14 necesidades de Virginia Henderson, jerarquización de Diagnósticos enfermeros, se ofreció una atención integral enfocada en cuidados especializados para cubrir las necesidades más afectadas en la persona. Conclusiones La aplicación del proceso de atención enfermero con base en la valoración de las 14 necesidades de Virginia Henderson, identificó que las necesidades más afectadas fueron; Oxigenación/Circulación y Evitar peligros, con la jerarquización se determinó que es imprescindible el conocimiento de enfermería en intervenciones especificas en el proceso postoperatorio de Tromboendarterectomía como: la detección del riesgo de alteraciones del ritmo cardiaco, valoración e intervenciones en insuficiencia respiratoria aguda, la propensión a eventos trombóticos secundarios a afección genética, para el logro de la recuperación de la salud de manera exitosa.

Abstract Introduction Since a pulmonary embolism (PE) can develop silently, more than 50 % of cases are not diagnosed until clear signs and symptoms are present. It is defined as the partial or total blockage of pulmonary circulation due to a blood clot which originated from the venous circulation elsewhere. Considered a cardiovascular urgency, it is a main cause of morbidity and mortality among hospitalized patients. Objective Based on the Nursing Process, to carry out a study case on a person who underwent surgery for Bilateral Pulmonary Thromboendarterectomy in the ICU of a Third Level of Care National Institute of Mexico City. Method This is a study case which followed the stages of the Nursing Process. An assessment guide of the 14 needs proposed by Virginia Henderson was utilized. Nursing diagnoses were ranked. An integral and specialized care addressing the patient's most important needs was offered. Conclusions The most important needs identified were: promoting oxygenation and circulation, and preventing risks. From the diagnoses analysis, it was determined that nursing knowledge is crucial in post thromboendarterectomy interventions, in terms of heart rate alteration risk detection, acute respiratory insufficiency assessment, and secondary thrombotic events prevention, all these in order to achieve a successful recovery.

Resumo Introdução A trombo embolia pulmonar (TEP) é uma doença que se apresenta com frequência de maneira silenciosa, o 50 % ou mais dos casos não se diagnostica. Define-se como a oclusão total ou parcial da circulação pulmonar, ocasionada por um coágulo sanguíneo proveniente da circulação venosa sistémica, incluídas as cavidades direitas e que, conforme sua magnitude, pode ou não originar sintomas. É considerada como uma urgência cardiovascular e constitui uma das principais causas de morbimortalidade em pacientes hospitalizados. Objetivo Desenvolver um Estudo de caso baseado no Processo de Atenção de Enfermagem na pessoa pós-perada de Tromboendarterectomia Pulmonar Bilateral na Unidade de cuidados intensivos post-cirúrgica de um Instituto Nacional de Terceiro Nível da Cidade do México. Método Estudo de Caso baseado nas etapas do processo enfermeiro, utilizou-se uma Guia de avaliação das 14 necessidades de Virginia Henderson, hierarquização de Diagnósticos enfermeiros, ofereceu-se uma atenção integral focalizada em cuidados especializados para cobrir as necessidades mais afetadas na pessoa. Conclusões A aplicação do processo de atenção enfermeiro com base na avaliação das 14 necessidades de Virginia Henderson, identificou que as necessidades mais afetadas foram; Oxigenação/Circulação e Evitar perigos, com a hierarquização determinou-se que é imprescindível o conhecimento de enfermagem em intervenções especificas no processo pós-operatório de Tromboendarterectomia como: a detecção do risco de alterações do ritmo cardíaco, avaliação e intervenções em insuficiência respiratória aguda, a propensão a eventos trombóticos secundários a afecção genética, para o sucesso da recuperação da saúde de maneira bem-sucedida.

Pulmonary endarterectomy outputs in chronic thromboembolic pulmonary hypertension. / Resultados de la tromboendarterectomía pulmonar en la hipertensión pulmonar tromboembólica crónica.

BACKGROUND AND OBJECTIVE: Pulmonary thromboendarterectomy surgery is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension; extremely high pulmonary vascular resistance constitutes a risk factor for hospital mortality. The objective of this study was to analyze the immediate and long-term results of the surgical treatment of chronic thromboembolic pulmonary hypertension in patients with very severe pulmonary hypertension. MATERIAL AND METHODS: Since February 1996, we performed 160 pulmonary thromboendarterectomies. We divided the patient population in 2 groups: group 1, which included 40 patients with pulmonary vascular resistance≥1090dyn/sec/cm-5, and group 2, which included the remaining 120 patients. RESULTS: Hospital mortality (15 vs. 2.5%), reperfusion pulmonary edema (33 vs. 14%) and heart failure (23 vs. 3.3%) were all higher in group 1; however, after one year of follow-up, there were no significant differences in the clinical, hemodynamic and echocardiographic conditions of both groups. Survival rate after 5 years was 77% in group 1 and 92% in group 2 (P=.033). After the learning curve including the 46 first patients, there was no difference in hospital mortality (3.8 vs. 2.3%) or survival rate after 5 years (96.2% in group 1 and 96.2% in group 2). CONCLUSIONS: Pulmonary thromboendarterectomy is linked to significantly higher morbidity and mortality rates in patients with severe chronic thromboembolic pulmonary hypertension. Nevertheless, these patients benefit the same from the procedure in the mid-/long-term. In our experience, after the learning curve, this surgery is safe in severe pulmonary hypertension and no level of pulmonary vascular resistance should be an absolute counter-indication for this surgery.

[Cerebral oximetry in pulmonary thromboendarterectomy with circulatory arrest]. / Oximetría cerebral en endarterectomía pulmonar con parada circulatoria.

Pulmonary thromboendarterectomy is an uncommon procedure and should be performed with circulatory arrest. One of the major concerns is the postoperative central neurological injuries. Perioperative brain oxygen monitoring is advisable in this surgical procedure for the early detection of brain hypoperfusion episodes and their intensity as well as any other postoperative episodes that can deteriorate the neurological outcome.

Tromboendarterectomía en hipertensión pulmonar tromboembólica crónica: reporte del primer caso clínico en Uruguay / Thromboendarterectomy in chronic thromboembolic pulmonary hypertension of the first clinical case report in Uruguay

La hipertensión pulmonar tromboembólica crónica (HPTEC) es una entidad subdiagnosticada y de alta morbimortalidad si no se accede a un tratamiento adecuado.El centellograma V/Q confirma la naturaleza tromboembólica de la hipertensión pulmonar (HP), pero es la arteriografía convencional el estudio que valora la topografía de los trombos y su accesibilidad a cirugía. El cateterismo cardíacoderecho confirma la HP, su severidad, y brinda parámetros de gran valor pronóstico. La HPTEC es la única etiología de hipertensión pulmonar con posibilidad de un tratamiento quirúrgico potencialmente curativo a través de la tromboendarterectomía pulmonar (TEE).Se reporta el primer caso de nuestro país de HPTEC tratada con TEE y evolución exitosa.

Chronic thromboembolic pulmonary hypertension ( CTEPH) is a delayed diagnosed disease with high morbidity and mortality, especially when untreated. Ventilation/perfusion lung scan confirms the thromboembolic etiology, but pulmonary angiography is still the gold standard diagnostic procedure for defining the extension and location of the disease and surgical indication. Right heart catheterization provides accurate prognostic and disease severity information. Pulmonary endarterectomy represents a potentially curative option in eligible patients.

Tromboendarterectomía pulmonar: tratamiento de elección para la hipertensión pulmonar tromboembólica crónica / Pulmonary thromboendarterectomy is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension

La tromboendarterectomía pulmonar es la terapéutica de elección para pacientes con hipertensión pulmonar tromboembólica crónica. Objetivos: Reportar la experiencia en tromboendarterectomía pulmonar a 18 años de seguimiento. Material y Métodos: Se analizaron retrospectivamente 41 pacientes entre Noviembre 1992 y Agosto 2010.Criterios de inclusión: presión arterial pulmonar media >30 mmHg y resistenciavascular pulmonar (RVP) >300 dinas/sg. cm-5. La angiografía pulmonar determinó la factibilidad quirúrgica. La supervivencia se calculó utilizando el método de Kaplan-Meier y para comparar 2 grupos log-rank test.Resultados: El 44% de los pacientes estaban en clase funcional IV. Los cambios hemodinámicos posteriores a la tromboendarterectomía fueron significativos p <0.001. La PAPm 53 ± 2 a 29 ± 2 mmHg, la RVP 857 ± 65 a 245 ± 25 dinas/sg. cm-5 y el IC 2,3 ± 0,1a 3 ± 0,1. La mortalidad hospitalaria fue 15%, en CF II-III 4% y en CF IV 33% (p=0.01). La mortalidad alejada fue 11%. El 93% de los pacientes mejoró su clase funcional. La supervivencia global a 1, 2, 5, 10 años fue del 85%, 82%, 75% y 71% respectivamente.La supervivencia por clase funcional mostró diferencias significativas (p=0.02). Conclusión: En nuestra experiencia la tromboendarterectomía pulmonar mostró beneficios en esta población de alto riesgo.

Pulmonary thromboendarterectomy is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension. Objective: To report our 18-years experience in pulmonary thromboendarterectomy. Material and Methods: Forty one patients were analyzed between November/1992 andAugust/2010. Inclusion criteria: mean pulmonary artery pressure (PAPm) >30 mmHg and pulmonary vascular resistance (PVR) >300 dinas/sec.cm-5. Pulmonary angiography determined the surgical feasibility. Survival was calculated using the Kaplan-Meiermethod and to compare the 2 groups log rank test. results: Pulmonary thromboendarterectomy is the treatment of choice for patients with chronicthromboembolic pulmonary hypertension. Objective: To report our 18-years experience in pulmonary thromboendarterectomy. Material and Methods: Forty one patients were analyzed between November/1992 andAugust/2010. Inclusion criteria: mean pulmonary artery pressure (PAPm) >30 mmHg and pulmonary vascular resistance (PVR) >300 dinas/sec.cm-5. Pulmonary angiography determined the surgical feasibility. Survival was calculated using the Kaplan-Meiermethod and to compare the 2 groups log rank test. Results: Forty four percent of the patients were classified in class IV. The hemodynamic changesafter pulmonary thromboendarterectomy were significant (p < 0.001). PAPm 53 ± 2 vs. 29 ± 2 mm Hg, PVR 857 ± 65 vs. 245 ± 25 dinas/sec. cm-5 and CI 2.3 ± 0.1 vs. 3 ± 0.1. In-hospital mortality was 15%; in classes II - III was 4%, and in class IV 33% (p = 0.01). Late mortality was 12%. Ninety three percent of the patients improved their functional class. Overall survival at 1,2, 5 and 10 years was 85%, 82%, 75% and 71% respectively. Survival according to functional class showed significant differences (p = 0.02).Conclusion: In our experience pulmonary thromboendarterectomy showed benefits even in thishigh risk population.

Tromboendarterettomía pulmonar bilateral en un aso de hipertensión arterial puulmonar tromboembólica crónica

El embolismo pulmonar, problema de salud pública mundial, presenta una incidencia anual estimada en 100,000 casos en Francia, 65,000 en Inglaterra y Gales, 630,000 en Estados Unidos y 60,000 nuevos casos por año en Italia. La mortalidad en casos no tratados asciende a 30% y con tratamiento adecuado es del 2-8%. La hipertensión arterial pulmonar tromboembólica crónica acontece en el 0.1 al 0.5% de los pacientes que sobreviven al evento embólico y es el resultado de la obstrucción de las arterias pulmonares principales por la presencia de émbolos pulmonares. La obstrucción del lecho vascular pulmonar contribuye al desarrollo de la hipertensión arterial pulmonar, la cual determina diversos grados de disfunción ventricular derecha y modifica la sobrevida en estos pacientes. La hipertensión arterial pulmonar tromboembólica crónica es potencialmente corregible mediante cirugía: tromboendarterectomía pulmonar con circulación extracorpórea, hipotermia profunda a 16°C, y perfusión cerebral retrógrada. En el presente artículo se reporta un caso de tromboembolia pulmonar crónica con obstrucción de 70% del lecho vascular pulmonar y disfunción ventricular derecha, sometido a cirugía de tromboendarterectomía pulmonar bilateral, observándose cambios ostensibles hacia la mejoría en los parámetros hemodinámicos, respiratorios y estado funcional. Estas variables mejoran la calidad de vida y sobrevida.

Pulmonary embolism is a global public health problem with estimated annual incidence of 100,000 cases ion France, 65,000 in England and Wales, 630,000 in the United States and 60,000 new cases per year in Italy. Mortality of untreated cases can be up to 30% and with adequate treatment of 2-8%. Chronic thromboembolic pulmonary arterial hypertension occurs in 0.1 to 0.5% of patients who survive to the embolic event, and is the result of main pulmonary artery obstruction due to the presence of pulmonary embolia. Obstruction of the pulmonary vascular bed contributes to the development of pulmonary arterial hypertension, which determines diverse degrees of right ventricular dysfunction and modifies patient survival expectancy. Chronic thromboembolic pulmonary arterial hypertension is potentially corrigible by pulmonary thromboendaterectomy with extracorporeal circulation, deep hypothermia at 16°C and retrograde cerebral perfusion. The present article reports a case of chronic pulmonary thromboembolia with 70% obstruction of the pulmonary vascular bed and right ventricle dysfunction, subjected to bilateral pulmonary thromboendarterectomy. Visible improvements in hemodynamic, respiratory and functional state parameters were observed. These variables increase life quality and survival expectancy.