Pulmonary thromboendarterectomy (PTE) surgery (also called pulmonary endarterectomy [PEA]) is the only treatment for CTEPH that can be curative, so it is the recommended first option for CTEPH patients.1 According to an International Prospective Registry, approximately 63% of CTEPH patients are operable.2
PTE should be offered to all eligible patients with CTEPH. Most patients experience significant improvements in symptoms and hemodynamics.2-4 The international registry of incident cases of CTEPH reported a 3-year survival of 90% in those receiving PTE versus 70% in those who did not have surgery.3
Patients who have operable CTEPH should be referred for surgery without delay5
PTE surgery is a complex bilateral procedure, which requires median sternotomy, cardiopulmonary bypass, deep hypothermia, and periods of circulatory arrest6
PTE allows for the removal of obstructing lesions, resulting in an improvement and often normalization of pulmonary hemodynamics7,8
Rates of residual pulmonary hypertension (PH) following PTE have been reported at 10% to 35%9-11
Images courtesy of Cameron D Wright, MD.
Images courtesy of Cameron D Wright, MD.
Cameron Wright, MD, of Massachusetts General Hospital performs pulmonary thromboendarterectomy (PTE) on a patient with CTEPH.
Early reocclusion prophylaxis using intravenous or subcutaneous heparin and subsequent lifelong anticoagulation is mandatory for all patients following PTE surgery1
Maximum benefits of PTE may not be observed for ≥6 months, making early and frequent post-operative follow-up essential1
Hemodynamic benefits may be seen immediately after surgery, but maximum benefits may not be observed for 6 months or longer1
Hemodynamic reevaluation should be conducted 6–12 months after surgery to exclude recurrent or residual symptomatic CTEPH1
Treatment with vasodilators may be beneficial for recurrent or residual CTEPH1
Following PTE, patients must be closely monitored and reassessed regularly.1 Up to one-third of patients may have residual CTEPH following PTE.9 Therefore, physicians should remain vigilant in assessing for signs of persistent/recurrent CTEPH for at least 1 year following surgery.1 Continuity of care between the pulmonary specialist and primary care physician is essential during this crucial time period.
1. Keogh AM, Mayer E, Benza RL, et al. Interventional and surgical modalities of treatment in pulmonary hypertension. J Am Coll Cardiol. 2009;54(suppl 1):S67-S77. 2. Pepke-Zaba J, Delcroix M, Lang I, et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry. Circulation. 2011;124(18):1973-1981. 3. Kim NH, Delcroix M, Jais X, et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J. 2019;53:1801915. 4. Galiè N, Humbert M, Vachiery JL, et al; ESC Scientific Document Group. 2015 ESC/ERS guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Heart J. 2016;37(1):67-119. 5. Kim NH, Delcroix M, Jenkins DP, et al. Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2013;62(suppl D):D92-D99. 6. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg. 2003;76(5):1457-1464. 7. Piazza G and Goldhaber SZ. Chronic thromboembolic pulmonary hypertension. N Engl J Med. 2011;364:351-360. 8. Rahnavardi M, Yan TD, Cao C, et al. Pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review. Ann Thorac Cardiovasc Surg. 2011;17(5):435-445. 9. Freed DH, Thomson BM, Berman M, et al. Survival after pulmonary thromboendarterectomy: effect of residual pulmonary hypertension. J Thorac Cardiovasc Surg. 2011;141(2):383-387. 10. Wittine LM and Auger WR. Curr Treat Options Cardiovasc Med. 2010;12:131-141. 11. Mayer E, Jenkins D, D’Armini A, et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011;141(3):702-710.