Pulmonary thromboendarterectomy is the definitive treatment for chronic pulmonary hypertension as the result of thromboembolic disease. Although pulmonary embolism (PE) is one of the more common cardiovascular diseases affecting Americans, pulmonary thromboendarteretomy remains an uncommon procedure, mainly because this form of chronic pulmonary hypertension remains an underdiagnosed condition.
When the diagnosis of thromboembolic pulmonary hypertension has been firmly established, the decision for PTE is based on the severity of symptoms and the general condition of the patient. There are three major reasons for considering PTE:
- Hemodynamic – to prevent or ameliorate right ventricular compromise caused by pulmonary hypertension
- Respiratory – to restore blood flow to ventilated but unperfused lung regions
- Prophylactic – to prevent progressive right ventricular dysfunction or retrograde extension of the obstruction, which might result in further cardiorespiratory deterioration or death, and to prevent secondary arteriopathic changes in the remaining patent vessels. The prevention of secondary arteriopathic changes is an important indication for surgery.
A typical patient will have a severely elevated pulmonary vascular resistance (PVR) level at rest, the absence of significant comorbid diseases unrelated to right heart failure, and the presence of chronic thrombi on angiography that is consistent with the measured PVR. Our program accepts patients spanning a broad clinical range, from young patients with dyspnea on exertion, to high-risk patients who have vascular disease in segmental and even subsegmental pulmonary arteries, to patients with advanced multi-system organ failure from cardiovascular compromise.
Contraindications (symptoms which make PTE inadvisable) are limited only to conditions judged to be unrelated to pulmonary hypertension or right heart dysfunction that are likely to independently limit patient survival in the near future. This expansion of the patient population considered acceptable for this operation is based largely on UCSD’s accumulated surgical experience, improved operative technique, and a multidisciplinary approach to postoperative care. Patients with thromboembolic pulmonary hypertension who are turned down at other centers are often treated successfully at our center.