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Ann Thorac Surg 1996;62:1255-1259
© 1996 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Predictors of Mortality in Pulmonary Thromboendarterectomy

Department of Surgery, University of Illinois Hospital and Clinics, Chicago, Illinois

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. The operative mortality associated with surgical thromboendarterectomy of the pulmonary arteries has decreased at the University of California in San Diego with the application of new techniques. For universal performance of the procedure, however, those factors that contribute to the high operative mortality must be identified. We analyzed our results in 34 consecutive patients undergoing pulmonary thromboendarterectomy to determine those preoperative factors that contribute to operative mortality.

Methods. Since 1983, 34 patients with severe, surgically correctable chronic thromboembolic pulmonary hypertension who were judged to be operable by pulmonary arteriography underwent pulmonary thromboendarterectomy. No patient was excluded because of right ventricular failure or hemodynamic severity of disease; the mean pulmonary artery pressure (PAP) was 54 mm Hg, the mean pulmonary vascular resistance (PVR) was 1,094 dynes•s•cm^-5, and all patients were in New York Heart Association functional class III or IV.

Results. Postoperative course was characterized either by swift recovery (mean length of stay, 13 days) or by rapid demise resulting from pulmonary or right ventricular failure, or both (overall operative mortality, 23%). In survivors, the mean PAP, PVR, cardiac output, and New York Heart Association functional class were significantly improved (p < 0.05). Patients who died had a significantly greater mean preoperative PAP than did those who survived (62.1 ± 1.2 versus 49.5 ± 2.3 mm Hg; p < 0.01) and significantly higher PVR (1,512 ± 116 versus 949 ± 85 dynes •s • cm^-5; p < 0.01). In addition, both a PVR of more than 1,100 dynes • s • cm^-5 and a mean PAP of more than 50 mm Hg could accurately predict operative mortality: operative mortality was six times greater in patients with a preoperative PVR of greater than 1,100 dynes • s • cm^-5 (41% versus 5.85%) and almost five times greater in those with a mean PAP of greater than 50 mm Hg (37% versus 8%). No intraoperative factors, including the use or duration of circulatory arrest, affected outcome.

Conclusions. Patients with severe hemodynamic disease (PVR >1,100 dynes • s • cm^-5 and PAP >50 mm Hg) have a high likelihood of operative mortality and perhaps should not undergo pulmonary thromboendarterectomy, except at institutions where the operation is performed frequently.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
See also page 1259.

Pulmonary thromboendarterectomy is effective and definitive treatment for chronic thromboembolic pulmonary hypertension. Although early reports documented a high operative mortality [1], refinements in technique have led to a dramatic improvement in out-come [2, 3]. Proper patient selection is critical when considering a patient for pulmonary thromboendarterectomy, as several risk factors have been identified that are associated with increased surgical morbidity and mortality [4].

For editorial comment, see page 1253.

Because our experience includes a series of patients with particularly severe disease in terms of the degree of pulmonary hypertension and right ventricular failure, we sought to determine whether certain preoperative clinical or hemodynamic variables could be used to predict postoperative success [4].

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Between September 1983 and November 1995, 75 patients with chronic thromboembolic pulmonary hypertension were evaluated for pulmonary thromboendarterectomy, 34 of whom were judged to be operable on the basis of pulmonary arteriographic findings. Pulmonary thromboendarterectomy was performed in these 34 patients at the University of Illinois Hospital at Chicago. The first 17 procedures were performed by a single surgeon (S.L., 1983–1989) and the next 17 by another surgeon (R.H., 1991–1995). The medical record, office file, and database of each patient were reviewed retrospectively. Particular attention was paid to the patient's preoperative and postoperative hemodynamic and pulmonary function. Nonstratified t tests were performed to determine whether preoperative pulmonary artery pressure (PAP), pulmonary vascular resistance (PVR), cardiac output, or New York Heart Association (NYHA) functional class significantly affected operative mortality. Subsequently, stratified ² analysis was performed for PAP (5–mm Hg increments between 40 and 60 mm Hg) and for PVR (100-dynes • s • cm^-5 increments from 800 to 1,600 dynes•s•cm^-5) to determine whether there were certain levels that could accurately predict operative mortality. A logistic model of analysis was employed to determine whether any combination of the following variables affected operative mortality: age of patient, surgeon, presence of cor pulmonale, NYHA functional class, right ventricular hypertrophy, arterial oxygen pressure, PAP, PVR, cardiac output, location of disease, and cardiopulmonary bypass temperature. Finally, the preoperative and postoperative PAP, PVR, cardiac output, and NYHA functional class were compared to determine the efficacy of the operation in survivors (nonstratified t tests). The final set of hemodynamic measurements obtained before removing the Swan-Ganz thermodilution catheter were used to obtain the postoperative values (second or third postoperative day), and the NYHA functional class was assessed at the 4- to 6-week outpatient follow-up visits.

The surgical technique was essentially that described by Utley [5], Daily [6], and Jamieson [2] and their associates and in all patients included median sternotomy with bicaval cannulation, profound hypothermia (17° to 20°C), and bilateral central pulmonary arteriotomies. If a patent foramen ovale was present, it was closed surgically, but tricuspid regurgitation (always moderate to severe) was never dealt with and resolved spontaneously after operation. In contrast to these other groups of investigators, however, we made every attempt to avoid using circulatory arrest and to perform the endarterectomy at decreased systemic perfusion rates. Circulatory arrest was used as part of the operative procedure in 70% of the survivors and 68% of the nonsurvivors, and since 1991, circulatory arrest (mean, 31 minutes) has been used in half of the patients.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
The mean age of the patients was 49 years (range, 23–84 years). Eighteen were women. Data are presented as mean ± the standard error of the mean. The mean preoperative PAP for the entire group was 53.5 ± 2.5 mm Hg and the mean PVC was 1,093.9 ± 116 dynes • s • cm^-5. The postoperative course was characterized by either swift recovery (26 patients, with mean length of stay of 13 ± 1 days) or by rapid demise resulting from pulmonary, cardiac, or multiorgan system failure (8 patients, with mean length of stay of 3.7 ± 0.4 days).

Overall, the operative mortality was 23%. Three patients died of reperfusion lung injury, 2 of right ventricular failure, 2 of respiratory failure, and 1 of multiorgan system failure. The major causes of death are listed in Table 1, but most patients had more than one contributing factor. All 6 patients who required extracorporeal membrane oxygenation (none since 1991) died of either reperfusion pulmonary edema or another type of pulmonary failure. Univariate analysis revealed that (1) preoperative PAP and PVR were higher (p < 0.01) in patients who died than in those who survived (PAP, 62.1 ± 1.2 versus 49.5 ± 2.3 mm Hg; PVR, 1,512 ± 116 versus 948.9 ± 85 dynes • s • cm^-5) (Fig 1); (2) when stratified in 100-dynes • s • cm^-5 increments from 800 to 1,600 dynes • s • cm^-5, a PVR of greater than 1,100 dynes • s • cm^-5 predicted operative mortality: 41% of such patients died versus only 5.85% of those with a PVR of less than 1,100 dynes • s • cm^-5 (p < 0.01) (Fig 2A); and (3) when the mean PAP was stratified by 5–mm Hg increments from 40 to 60 mm Hg, a PAP of more than 50 mm Hg also predicted operative mortality (mortality, 37% versus 8%; p < 0.01) (Fig 2B). None of the variables listed in Table 1 could, in combination, predict operative mortality (odds ratios, >0.5 and <2.0 in the logistic regression model).

View larger version (28K): [in this window] [in a new window]   Fig 1. . Preoperative and postoperative mean pulmonary artery pressure (PAP) (A) and pulmonary vascular resistance (PVR) (B) related to outcome. (p < 0.01 for each variable.)

View larger version (26K): [in this window] [in a new window]   Fig 2. . Operative mortality stratified by (A) preoperative pulmonary vascular resistance (PVR) in 100-dyne • s • cm-5 increments and (B) preoperative mean pulmonary artery pressure (PAP) in 5-mm Hg increments. (p < 0.05 for each variable.)

View larger version (29K): [in this window] [in a new window]   Fig 3. . Preoperative versus postoperative characteristics in survivors. (p < 0.05 for each variable.) (CO = cardiac output; NYHA = New York Heart Association; PAP = pulmonary artery pressure; PVR = pulmonary vascular resistance.)

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Chronic thromboembolic pulmonary hypertension is a term proposed by Moser and associates [8] to describe a progressively debilitating thrombotic obstruction of the pulmonary arterial tree that eventually leads to death stemming from right ventricular failure. Others have reported on the incidence, pathophysiology, natural history, and differential diagnosis of the condition [2, 3, 8, 9]. Unlike primary pulmonary hypertension, chronic thromboembolic pulmonary hypertension is a surgically correctable condition. The operation itself, once considered a formidable undertaking, can now be accomplished with a very acceptable mortality and minimal morbidity [2, 3, 8]. In the past, the disease was dramatically underdiagnosed, but its increasing recognition has resulted in a marked increase in the number of patients considered for definitive surgical intervention.

This series of 34 patients operated on by two different surgeons had very severe hemodynamic disease: their mean PAP was 54 mm Hg and their mean PVR was almost 1,100 dynes • s • cm^-5. By comparison, the mean PVRs cited in three consecutive reports describing the experience at the University of California in San Diego were 897, 813, and 937 dynes • s • cm^-5, respectively [2, 3, 6]. Our review of the world literature has failed to reveal any additional reports that cite a mean PVR higher than that in our group of patients.

Stratification of operative mortality by the preoperative PVRs and PAPs yielded the most significant conclusion of the study: the operative mortality in patients with a PVR of greater than 1,100 dynes • s • cm^-5 was sixfold greater than that in patients with a PVR of less than 1,100 dynes • s • cm^-5. Whereas the mortality in those with a PVR of less than 1,100 dynes • s • cm^-5 was 5.8%, the mortality in those with a PVR of greater than 1,100 dynes • s • cm^-5 was 41%. Similarly, the mortality in those with a mean PAP of greater than 50 mm Hg was fivefold greater than that in those with a PAP of less than 50 mm Hg. It would thus appear that surgical groups should avoid performing pulmonary thromboendarterectomy in patients with extreme elevations of PVR and PAP, especially during the learning curve for this procedure. Although the overall operative mortality appears high (23%), it is important to note that, for those patients with a preoperative PVR of less than 1,100 dynes • s • cm^-5 (mean, 948 dynes& bull; s • cm^-5), the operative mortality of 5.8% is almost identical to that reported by Jamieson for his last 150 patients (8.5%), whose mean PVR was 937 dynes • s • cm^-5.

The only significant difference in the technique performed at our institution is that circulatory arrest is not considered mandatory or desirable. We have the impression that it leads to greater postoperative morbidity and for this reason try to avoid using it completely. We have been able to perform the procedure completely without circulatory arrest in 8 of the past 17 patients, with a mean circulatory arrest time of 31 minutes in the other 9. Our technique involves the use of low-flow hypothermic cardiopulmonary bypass. Usually the flow is maintained at 1 L/min, but occasionally it must be lowered to 500 mL/min. The endarterectomy can be accomplished even in the face of backbleeding, especially if the entire specimen on each side is kept intact. The pulmonary artery is essentially peeled off the intact specimen, rather than vice versa, until the feathered ends "pop" out of each segmental or subsegmental arterial branch. (Figure 4 shows an operative specimen removed without the use of circulatory arrest.) Because circulatory arrest is avoided, we have abandoned using electroencephalographic monitoring for most patients and use less steroids and barbiturates than the group in San Diego. None of the past 17 patients has had serious motor or cognitive impairment, reperfusion pulmonary edema has not been problematic, and no patient has required extracorporeal membrane oxygenation since 1991.

View larger version (146K): [in this window] [in a new window]   Fig 4. . Operative specimen removed without circulatory arrest.

Finally, it is important to reemphasize that our 34 patients were selected from approximately 75 patients with documented chronic thromboembolic pulmonary hypertension who underwent pulmonary angiography, but that half were considered to have inoperable disease on the basis of the finding of "distal disease." We have now learned from Jamieson and Moser (personal communication) that virtually all patients are anatomically operable. Stratification by preoperative hemodynamics thus assumes even more importance in the selection of patients for operative intervention if high operative mortality is to be avoided.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We thank Mi Sun Yu, PhD, for her assistance in statistical analysis. We are also indebted to Drs Stuart W. Jamieson and Kenneth M. Moser for their invaluable assistance in helping us develop our pulmonary thromboendarterectomy program.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Presented at the Thirty-second Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 29-31, 1996.

Address reprint requests to Dr Hartz, University of Illinois, 1740 W Taylor, Chicago, IL 60612.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

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4. Daily PO. Chronic pulmonary embolism. Adv Cardiac Surg 1993;4:25–46.[Medline]
5. Utley JR, Spragg RG, Long WB III, Moser KM. Pulmonary endarterectomy for chronic thromboembolic obstruction: recent surgical experience. Surgery 1982;92:1096–102.[Medline]
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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Renee S. Hartz John G. Byrne Sidney Levitsky Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hartz, R. S. Articles by Rich, S.