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Ann Thorac Surg 2001;72:18-19
© 2001 The Society of Thoracic Surgeons
ur-Poumon, Blvd Fleming, 25030, Besancon, France
e-mail: chocron{at}usa.net
Venous thromboembolism is the third most prevalent cardiovascular disease after coronary artery disease and stroke. Remy-Jardin and coworkers [1] reported that only 48% of patients showed complete resolution of their acute thrombotic obstruction and 13% presented chronic thromboembolic changes 11 months after treatment for acute pulmonary embolism.
Thromboembolic pulmonary hypertension has a very poor prognosis: from 30% to 10% 5-year survival according to mean pulmonary artery pressure. Despite promising functional results obtained with pulmonary vasodilators, medical therapy does not seem to be effective for long-term survival. The San Diego Medical Center (University of California), with over 1,300 procedures performed, is the most experienced group in pulmonary endarterectomy surgery. Their published data showing improved results year after year have encouraged surgeons to perform pulmonary endarterectomy, as proved by the increasing number of cases published. As isolated pulmonary endarterectomy is in itself a challenging operation, one could be tempted to screen patients. One way would be to select patients with a mean pulmonary vascular resistance lower than 1,100 dynes · sec-1 · cm-5, since operative mortality appears to be greater above this level. Another way would be to exclude patients with concomitant heart disease. This retrospective study compares the surgical outcome of patients having undergone pulmonary endarterectomy with concomitant procedures (mainly myocardial revascularization) to patients having undergone isolated pulmonary endarterectomy. The concomitant procedure was performed during rewarming, so the cardiopulmonary bypass time was equivalent in the two groups. The concomitant procedure did increase hospital stay length and postoperative complications, but did not modify survival or decrease in pulmonary vascular resistance, despite the older age of the study population. With a 93.3% survival rate at 1 year, pulmonary endarterectomy gives better results than transplantation, even in these complicated patients. This is all the more interesting in that transplantation could not be proposed to most of the patients due to their age.
Two elements of this study limit its conclusions: (1) the possible selection bias due to the retrospective character of the study; and (2) the small size of the subgroups included in the combined group, which preclude subgroup analysis. Nevertheless, the authors have made it clear that pulmonary endarterectomy may be performed safely in conjunction with other cardiac operations.
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