Original article
General thoracic
Symptoms Are More Useful Than Echocardiography in Patient Selection for Pulmonary Endarterectomy

https://doi.org/10.1016/j.athoracsur.2017.05.024Get rights and content

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) is still largely underdiagnosed in the general population. Although transthoracic echocardiogram (TTE) is recommended to screen for CTEPH, it may not detect patients with chronic thromboembolic disease (CTED) and mild or exercise-induced pulmonary hypertension (PH) who could also benefit from pulmonary endarterectomy (PEA).

Methods

All patients referred to our CTEPH program with persistent mismatched perfusion defects on ventilation–perfusion (VQ) scan between January 2005 and June 2015 were divided into three groups according to TTE and right heart catheterization (RHC) as follows: (1) typical CTEPH group (PH on RHC and TTE), (2) TTE-negative (neg) CTEPH group (PH on RHC, but not TTE), or (3) CTED group (no PH on RHC and TTE).

Results

Of 225 patients with abnormal VQ scans, 188 (84%) had typical CTEPH, 15 had TTE-neg CTEPH, and 22 had CTED. PEA was performed in 179 patients (80%). Reasons for exclusion in CTEPH patients included primarily distal disease (n = 11) and comorbidities (n = 10). In contrast, the absence of functional limitation was the main cause of exclusion in CTED patients (75% versus 3% in CTEPH patients, p < 0.0001). The 90-day mortality rate after PEA was 4% in the typical CTEPH group and 0% in the TTE-neg CTEPH and CTED groups. Pulmonary arterial pressures and functional class significantly improved after PEA in all three groups.

Conclusions

Patients with mild CTEPH can benefit from PEA, but may not be detected by TTE. Symptomatic patients with functional limitation and persistent mismatched perfusion defects on VQ scan should undergo further investigations with pulmonary angiogram and RHC.

Section snippets

Material and Methods

After approval by the University Health Network Institutional Research Ethics Board, we retrospectively reviewed all patients referred to the Toronto CTEPH Program between January 2005 and June 2015. Patients with normal VQ scans were excluded. Patients with mismatched perfusion defects on VQ scans were then divided into three groups according to TTE and right heart catheterization (RHC) performed at the time of their assessment: (1) typical CTEPH group (PH likely on TTE confirmed by RHC), (2)

Results

From January 2005 until June 2015, 252 patients were reviewed in the CTEPH clinic at our center. Ten patients were found to have a normal VQ scan, and 17 patients did not have a RHC and were therefore excluded from this analysis. Of 225 patients with a persistently abnormal VQ scan despite 3 months of anticoagulation, 188 (84%) were likely to have PH on TTE, 21 (9%) possibly had PH, and 16 (7%) were unlikely to have PH on TTE at the time of their assessment. Echocardiographic findings

Comment

CTEPH is increasingly recognized as one of the main causes of right heart failure. PEA has been shown to be a durable treatment for this disease, improving both symptoms and prognosis [1]. CTEPH as a disease encompasses patients with a wide range of disease severity. By definition, PH is present when the mean PAP is ≥25 mm Hg [6]. Therefore, CTEPH patients range from those with mild PH to severe PH with right heart failure and multisystem organ dysfunction. As CT technology improves, rates of

References (9)

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