Selection criteria for PEA (UCSD)

Transcription

1 Chirurgische behandeling van chronische longembolen Pulmonale Thrombendarterectomie PTEA Selection criteria for PEA (UCSD) NYHA 3-4 PVR > 300 dynes.sec.cm-5 accessibility of the thrombi - strictures (main, lobar, and segmental arteries) absence of co-morbid condition willingness of the patients to accept the risks 1

2 OPERABILITY ASSESSMENT ESC PE guidelines, Konstantinides et al, EHJ 2014 Pulmonary angiography o Gold standard o Typical findings 1,2 Pouching Webs or bands w/wo post-stenotic dilation Wall irregularities Abrupt narrowing Total occlusion of segmental or larger branches 1 Nicod et al, Ann Intern Med 1987; 107: Auger et al, Radiology 1992; 182:

3 How to assess the degree of small vessel involvement? Analysis of pressure decay curves after pulmonary arterial occlusion Notch ratio calculation Subpleural perfusion 5 Subpleural perfusion 6 Tanabe et al, Chest 2012; 141: 929 3

4 PEA procedure San Diego technique Median sternotomy Cardiopulmonary bypass Deep hypothermic (18-20 C) circulatory arrest (DHCA) (periods < 20 min) Dissection of the vena cava superior Incision in right pulmonary artery Establishing the correct endarterectomy plane ( stripping ) Right endarterectomy under circulatory arrest Closure right pulmonary artery; start CPB Incision in left pulmonary artery Left endarterectomy under circulatory arrest Daily et al, J Cardiac Surgery 1989; 4: Jamieson et al, J Thorac Cardiovasc Surg 1993; 106: Thistlethwaite et al, Ann Thorac Cardiovasc Surg 2008;14:274 Technique 4

5 Pulmonary endarterectmy (PEA) PAPsys 100 to 55 mmhg 5

6 Surgical Management and Outcome of Patients with Chronic Thromboembolic Pulmonary Hypertension (CTEPH): Results from a European Prospective Registry Eckhard Mayer 1 ; David Jenkins 2 ; Jaroslav Lindner 3 ; Andrea D Armini 4 ; Jaap Kloek 5 ; Bart Meyns 6 ; Lars Bo Ilkjaer 7 ; Walter Klepetko 8 ; Marion Delcroix 6 ; Irene Lang 8 ; Joanna Pepke-Zaba 2 ; Gerald Simonneau 9 ; and Philippe Dartevelle Bad Nauheim, Germany; 2 Cambridge, United Kingdom; 3 Prague, Czech Republic; 4 Pavia, Italy; 5 Amsterdam, Netherlands; 6 Leuven, Belgium; 7 Aarhus, Denmark; 8 Vienna, Austria; 9 Paris, France and 10 Le Plessis Robinson, France. JTCVS 2011 Inclusion Criteria 27 CTEPH centers (26 European, 1 Canadian, 17 PEA centers, inclusion from 2/2007 to 1/2009) only incident cases (diagnosis < 6 months prior to inclusion) diagnosis CTEPH confirmed by specific investigations and imaging no PAH-specific treatment prior to diagnosis at least 3 months of anticoagulation 6

7 CTEPH Registry - Operability % all operated non-operated all patients operable non-operable Surgical Patient Characteristics number of patients n = 386 median age (y.) 60 (18 to 84, 54 % male) previous acute PE n = 308 (79.8 %) time from first symptoms to diagnosis 14.6 (0.5 to 440) (months) median mpap at rest (mmhg) 48 (17 to 80) median PVR at rest (dyn. s. cm -5 ) 728 ( ) PAH-specific therapy after diagnosis n = 107 (27.7 %) 7

8 Mortality Rate after PEA in-hospital death n = 18/386 (4.7 %) death within 1 year n = 27/386 (7 %) Surgical Complications %

9 Risk Factors Univariate Analysis In-hospital mortality Odds ratios [95% CL] (p-value) One-year mortality Odds ratios [95% CL] (p-value) no PAH-specific treatment after diagnosis 0.36 [0.14, 0.94] (p = ) ns time from last PE to PEA (per year) 1.09 [1.01, 1.17] (p = ) ns PVR at diagnosis (per 100 dyn.s.cm -5 ) 1.16 [1.05, 1.27] (p = ) 1.10 [1.01, 1.19] (p = ) 6MWD at diagnosis (per 100 m) 0.61 [0.40, 0.93] (p = ) 0.58 [0.41, 0.82] (p = ) PVR at the end of intensive care (per 100 dyn.s.cm -5 ) 1.27 [1.08, 1.50] p = [1.01, 1.36] p = Risk Factors Multivariate Analysis In-hospital mortality Odds ratios [95% CL] (p-value) One-year mortality Odds ratios [95% CL] (p-value) use of PAH-specific treatment at diagnosis ns ns time from last PE to PEA (per year) ns ns PVR at diagnosis (per 100 dyn.s.cm -5 ) ns ns 6MWD at diagnosis (per 100 m) ns 0.40 [0.21, 0.79] p = PVR at the end of intensive care (per 100 dyn.s.cm -5 ) 1.79 [1.11, 2.88] p = [1.08, 1.83] p =

10 Pulmonary Vascular Resistance dyn. s. cm CL:[702,827] 248 CL:[230,263] 235 CL:[211,255] preop. (n=252) postop. (n=252) 1 year (n=70) Mortality PVR at Diagnosis % in-hospital death < >1200 dyn. s. cm -5 p < 0.05 vs. <400, Fisher s exact test 10

11 Mortality Center Expertise 12,00 10,00 8,00 p = n.s. % in-hospital death 6,00 4,00 2,00 0, all (17 c.) n=1-10 (6 c.) n=11-50 (8 c.) n>50 (3 c.) PEA per year Wilcoxon 2-sample test Conclusions In specialized centers, the surgical management of incident, newly diagnosed CTEPH patients provides favorable results as indicated by low operative mortality and improvement of exercise capacity and hemodynamics. As low exercise capacity and high PVR are risk factors for survival, earlier diagnosis seems mandatory and referral for PEA surgery to expert centers may not be delayed. Future registry follow-up data will support critical decision-making regarding operability and treatment options for these patients. 11

12 CTEPH referral UZLeuven referral PEA CTEPH = PEA referral UZLeuven PEA inhospital mortality CTEPH = 355; PEA =

13 PEA - Patient characteristics Mean SD Median (range) UZL 2015 UCSD Jamieson 2003 Paris Dartevelle 2004 Papworth Freed 2008 Pavia Corsico 2008 Nieuwegein Saouti 2009 n Age, y 60 (11-92) 52 (8-84) 55 (15-80) 55? (11-84) (23-74) Gender, % male NYHA (I-II-III-IV), % MWD, m PAP, mmhg CI, L/min/m PVR, dsc TPVR, dsc Mortality, % PEA inhospital mortality UZLeuven n % PEACOG study, 74 patients 1.4% Vuylsteke et al Lancet 2011;378:1379 UCSD, last 500 patients 2.2% Madani et al Ann Thor Surg 2012;94:97 European prospective registry 4.7% Mayer et al J Thorac Cardiovasc Res 2011;141:

14 PEA vs BPA vs medical treatment Experience PEA BPA Medical treatment >7000 cases Multiple publications 243 cases reported 7 case series 1000 cases reported 13 case series 3 RCT Procedures 1 Multiple (3-5) - Invasiveness High Moderate Low Treatment effect (decrease in PVR) -65% (San Diego and CTEPH registry) (1,2) % (4-7) % (case series) % (RCT) (8-10) Long-term outcome Better 3-year survival compared to medical treatment (3) >5-year survival reported 3-4 years 5 years (1) Madani et al, Ann Thorac Surg 2012; (2) Mayer et al, J Thorac Cardiovasc Surg 2011; (3) Simonneau et al, ATS 2013; (4) Sugimura et al, Circ J 2012; (5) Mizoguchi et al, Circ Cardiovasc Interv 2012; (6) Andreassen et al, Heart 2013; (7) Fukui, ERJ 2014; (8) Jais et al, JACC 2008; (9) Suntharalingam et al, Chest 2008; (10) Ghofrani et al, NEJM 2013 Courtesy of D Jenkins 14