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J Thorac Cardiovasc Surg 2003;126:1228-1229
© 2003 The American Association for Thoracic Surgery
Letter to the editor |
a Division of Cardiothoracic Surgery, University of California, San Diego, San Diego, CA 92103-8892, USA
Reply to the Editor:
We appreciate the attention that Dr Riedel has paid to our article. He brings up several points that deserve clarification.
First, selection criteria for pulmonary endarterectomy are multiple, and determination of candidacy for pulmonary endarterectomy is based on a composite of factors. Our selection criteria for surgery include but are not limited to just New York Heart Association (NYHA) class III and IV patients. We offer pulmonary endarterectomy to patients with NYHA class I and II disease, although only 1 in our series was in NYHA class I. The long-term survival of patients with untreated chronic thromboembolic pulmonary hypertension, irrespective of symptoms, is poor.1 In our hands, the mortality associated with pulmonary endarterectomy (4.5%) is much less than the published mortality associated with untreated thromboembolic pulmonary hypertension (32.6% in 1 series with an average follow-up of 18.7 months2). In our experience, pulmonary endarterectomy is not only associated with improved long-term survival but also a better quality of life for patients who previously suffered from this disease.3 Furthermore, we have become increasingly aware that the remaining open pulmonary vascular bed after thromboembolic occlusion can become irreparably damaged by prolonged exposure to the flow and pressure changes occasioned by vascular occlusion in other areas.4 For these reasons, we believe that pulmonary endarterectomy should be offered to all patients with thromboembolic pulmonary hypertension, including those with less clinical symptomatology.
Second, patients in group 1 of our study were comprised of individuals with chronic pulmonary hypertension who had fibrotic thromboembolic obstruction of their main and/or lobar pulmonary arteries as well as fresh clot that occurred either as a result of recurrent pulmonary emboli or as a secondary consequence of this obstructive process (see Figure 1). No amount of anticoagulation or thrombolytic therapy would have altered the distal fibrotic obstruction that was responsible for the patients' pulmonary hypertension. Incidentally, proximal clot propagation occurs even in the setting of therapeutic anticoagulation, as more than 80% of the group 1 patients referred to us for operation had been on coumadin for a period of longer than 3 months. We do not treat patients with acute pulmonary embolism with pulmonary endarterectomy; this is a different disease.
Third, although we have performed more than 1600 pulmonary endarterectomies in the last 10 years at the University of California, San Diego, we still do not have a completely foolproof method of determining location of pulmonary vascular obstructive disease in all patients. We have found that pulmonary angiography is the imaging modality that provides the best preoperative assessment of thromboembolic obstruction. However, using a combination of assessments, including angiography, angioscopy, ventilation-perfusion scanning, spiral computed tomography (CT) scanning, and 3-dimensional CT angiography, there are still a few patients in whom disease location is not diagnosed with certainty prior to surgery. It is precisely this small group of patients (with distal small vessel disease, or "primary" pulmonary hypertension, type 4) that represent our treatment failures and in retrospect would not have been operated on. These patients, incidentally, had failed other therapeutic measures to reduce their pulmonary pressures.
Fourth, Table 3 in our paper addresses 1-month survival data, while Table 4 lists complications we have seen in the perioperative period after this operation. We report complications we have seen with this operation, and they represent a rate similar to (or even less than) the complication rates seen for other major cardiovascular operations. Rather than operating upon lower risk patients, in recent years we have expanded the eligible patient population for pulmonary endarterectomy to include older, sicker individuals, often with other concomitant heart disease. In any event, postoperative complications per se are not a reason to exclude patients from a lifesaving operation; rather, they represent an accurate depiction of our clinical experience with the surgical treatment of chronic thromboembolic disease over a wide spectrum of patient age groups and disease severity.
Finally, although comparisons between medically managed chronic thromboembolic disease and pulmonary endarterectomy have not been systematically made in prospective randomized trials, we believe that such trials would essentially be unethical, given the disparity in published survival statistics. The cumulative data from our institution leave no doubt that pulmonary endarterectomy is the superior treatment choice for management of pulmonary hypertension caused by chronic thromboembolic disease to the lungs.
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  H. J. Reesink, M. N. van der Plas, N. E. Verhey, R. P. van Steenwijk, J. J. Kloek, and P. Bresser Six-minute walk distance as parameter of functional outcome after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 510 - 516. [Abstract] [Full Text] [PDF]
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