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Vol. 45. Issue S6.
Hipertensión pulmonar tromboembólica crónica
Pages 30-34 (June 2009)
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Vol. 45. Issue S6.
Hipertensión pulmonar tromboembólica crónica
Pages 30-34 (June 2009)
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Tratamiento quirúrgico en pacientes con hipertensión pulmonar tromboembólica crónica
Surgical treatment in patients with chronic thromboembolic pulmonary hypertension
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David Sánchez Lorente, Paolo Macchiarini??
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p.macchiarini@thoraxeuropa.eu

Autor para correspondencia.
Servicio de Cirugía Torácica, Hospital Clínic i Provincial de Barcelona, Universitat de Barcelona. Barcelona, España
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La hipertensión pulmonar tromboembólica crónica (HPTEC), con una historia natural con baja superviviencia a largo plazo, cada vez se diagnostica con más frecuencia. La endarterectomía pulmonar es el tratamiento de elección, pudiendo llegar a ser curativo. Consiste en una verdadera endarterectomía a través de esternotomía media, en circulación extracorpórea y períodos de parada circulatoria bajo hipotermia. Previamente a la cirugía debe realizarse: ecocardiograma transesofágico, gammagrafía pulmonar ventilación/perfusión, cateterismo cardiaco derecho, angiografía pulmonar y tomografía helicoidal computarizada. La indicación de cirugía en la HPTEC debe tomarse tan pronto como se realice su diagnóstico, antes de que se desarrolle una arteriopatía en los territorios no obstruidos e HPTEC severa. La única contraindicación absoluta de endarterectomía pulmonar es la presencia de una severa enfermedad pulmonar subyacente, obstructiva o restrictiva. No hay grado de obstrucción embólica inaccesible ni grado de fallo ventricular derecho o nivel de resistencia vascular pulmonar (RVP) que sean inoperables. Sin embargo, el pronóstico empeorará a mayor presión pulmonar preoperatoria y a mayor RVP postoperatoria. La mortalidad de la endarterectomía pulmonar es del 4-10%, y la principal causa de muerte postoperatoria es la persistencia de altas presiones pulmonares y RVP, seguida del edema de reperfusión, que requiere prolongación de la ventilación mecánica, vasodilatadores pulmonares y, en ocasiones, soporte respiratorio extracorpóreo. A largo plazo, el 75% de los pacientes sometidos a endarterectomía pulmonar presenta unos resultados funcionales buenos y la mitad recupera una tolerancia al ejercicio correcta. El trasplante pulmonar es una alternativa para los pacientes sin opción de endarterectomía pulmonar, aunque con peores resultados y mayor mortalidad.

Palabras clave:
Hipertensión pulmonar tromboembólica crónica
Tromboendarterectomía pulmonar
Endarterectmía pulmonar
Circulación extracorpórea
Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH), which has a natural history with low long-term survival, is increasingly being diagnosed. Pulmonary endarterectomy (PE) is the treatment of choice, which can be curative. This technique consists of a true endarterectomy through a midline sternotomy with extracorporeal circulation and periods of hypothermic circulatory arrest. The following procedures should be performed before surgery: transesophageal echocardiogram, ventilation-perfusion pulmonary scintigraphy, right cardiac catheterism, pulmonary angiography and helicoidal computed tomography. Surgery should be indicated in CTEPH as soon as the diagnosis is made, before arteriopathy develops in the non-obstructed regions and CTEPH becomes severe. The only absolute contraindication to PE is the presence of obstructive or restrictive, severe underlying pulmonary disease. There are no inaccessible grades of embolic obstruction, or grade of right ventricular failure or level of pulmonary vascular resistance (PVR) that are inoperable. However, prognosis worsens with greater preoperative pulmonary pressure and greater postoperative PVR. Mortality in PE is 4-10% and the main cause of postoperative death is the persistence of high pulmonary pressures and PVR, followed by reperfusion edema, which requires prolongation of mechanical ventilation, the use of pulmonary vasodilators and, sometimes, extracorporeal respiratory support. In the long-term, 75% of patients undergoing PE show good functional results and half recover adequate exercise tolerance. Pulmonary transplantation is an alternative for patients unsuitable for PE, although with worse results and greater mortality.

Keywords:
Chronic thromboembolic pulmonary hypertension
Pulmonary thromboendarterectomy
Pulmonary endarterectony
Cardiopulmonary bypass
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Copyright © 2009. Sociedad Española de Neumología y Cirugía Torácica
Archivos de Bronconeumología

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