DISTAL PULMONARY THROMBOENDARTERECTOMY: IS IT WORTH IT?

DISTAL PULMONARY THROMBOENDARTERECTOMY: IS IT WORTH IT? Bob Moraca, MD Associate Professor of Surgery Surgical Director of The CTEPH Program Director of Thoracic Aortic and Arrhythmia Surgery Allegheny General Hospital Pittsburgh, PA

CTEPH: Distal Disease I. Defining Distal Disease in CTEPH II. Surgical Techniques for Type III Disease II. Contemporary Results of PTE with Type III Disease

CTEPH: Distal Disease What is distal disease? Never use an adjective when you can use a number.. John A. Ryan, Jr., MD

CTEPH: Distal Disease III IV

CTEPH: Distal Disease What is distal disease? Distal Disease = Inoperable (Type IV) Subsegmental Disease Distal Disease = Higher Risk (Type III) Segmental Disease Amendable to PTE

CTEPH: Type III Disease Increasing Incidence of Surgical Type III Disease University of California San Diego Type III 27% 39% European Centers Type III 32 37% (Ann Thorac Surg 2012;94:97 103 J Thorac Cardiovasc Surg 2014;148:1005-12

Patient Comorbidities Higher baseline PVR CTEPH: Type III Disease Increased Surgical Risk Poor preoperative RV function Typically high preoperative oxygen requirements

CTEPH Type III Disease Increased Surgical Risk

CTEPH: Type III Disease Increased Surgical Risk

PVR Associated with Mortality J Thorac Cardiovasc Surg. 2011 Mar;141(3):702-10

CTEPH: Type III Disease Clues to concomitant small vessel disease Pathology: PAH like small vessel arteriopathy Imaging: discordance between hemodynamic and perfusion defects Clinical: hemodynamic progression without new perfusion defects Eur Respir Rev 2013;22:258-264

Pulmonary Thromboendarterectomy Guidelines Type III Disease Proc Am Thorac Soc Vol 3. pp 601 607, 2006

Patient Comorbidities Higher baseline PVR CTEPH: Type III Disease Increased Surgical Risk Poor preoperative RV function Typically high preoperative oxygen requirements Operative Issues Difficult to access surgically Longer operative time and circulatory arrest times Potential increase postoperative airway hemorrhage Overall higher operative mortality

Center Experience and Operability Pepke-Zaba J et al, Circulation 2011

CTEPH: Type III Disease I. Defining Distal Disease in CTEPH II. Surgical Techniques for Type III Disease

Patient Selection and Preoperative Optimization

Techniques for Type III Disease Preparation Preoperative Preparation for Type III Disease Thorough review of imaging and hemodynamics Provocative PVR Assessment Optimization of preoperative comorbidities

Techniques for Type III Disease Mentors

Disaster Preparation Techniques for Type III Disease Preparation Vascular Injury Refractory Pulmonary Hypertension Right Ventricular Failure Intra-operative Reperfusion Edema.

1. Visualization Techniques for Type III Disease Equipment Powerful Light Source Increased focal length of surgical loupes

Original PTE Instruments

Current PTE Instruments

Techniques for Type III Disease Intraoperative 1. Deep Hypothermic Circulatory Arrest (Core Temperature 18-20 C*)

Surgical Techniques for Type III Disease 1. Deep Hypothermic Circulatory Arrest (Core Temperature 18-20 C*) 2. Intermittent Cerebral Perfusion Every 20-25 minutes (UCSD) Every 5-10 minutes (Pavia ) Continuous Bilateral Antegrade Cerebral Perfusion (Cambridge, Melbourne, AGH) Important no perfusion during the distal endarterectomy Bloodless field

CTEPH: Type III Disease

Techniques for Type III Disease Intraoperative 1. Ventilate the lungs with several Valsalva breaths during circulatory arrest to clear any residual blood. 2. May need to start the endarterectomy plane with a intimal dissection and work your way to the distal vessels. 3. Irrigate the lung with saline intermittently to remove debris for a clearer dissection plane. 4. Post distal PTE, full pulmonary artery with saline and ventilate to look for bubbles indicating a vascular vessel compromise.

CTEPH: Type III Disease Contemporary Results of PTE with Type III Disease University of California San Diego, San Diego, CA Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy

(Ann Thorac Surg 2012;94:97 103

Overall Mortality PVR <1000 dyn-s-cm5 PVR > 1000 dyn-s-cm5 Group 1 (n=1000) 2.0% 9.3% Group 2 (n=500) 1.6% 4.3 % (Ann Thorac Surg 2012;94:97 103

J Thorac Cardiovasc Surg 2014;148:1005-12

Hospital Mortality Proximal 6.3% Distal 8.1% Overall 6.9% Main Causes of Mortality Airway Bleeding (30%) Persistent PH (22%) Lung Infection (22%) Irreversible Right Heart Failure (9%) J Thorac Cardiovasc Surg 2014;148:1005-12

J Thorac Cardiovasc Surg 2014;148:1005-12

CTEPH: Type III Disease I. Defining Distal Disease in CTEPH II. Contemporary results of PTE with Type III Disease I. Mortality 4-8% compared with 0.9 6% II. Reduction in PVR and PA Pressure Similar reductions with proximal to near normal values. III. Long-term Survival Similar to proximal disease proximal to near normal values. IV. Functional outcomes Similar to proximal disease proximal to near normal values.

Summary I. There is an increasing incidence of Type III disease in contemporary large surgical series of PTE. II. Patients with Type III disease tend to have increased perioperative comorbidities and operative complexities. III. Excellent long-term outcomes with reductions in PVR, 6mw and survival can be achieved in patients with Type III disease similar to patients with proximal disease. IV. Fluency with bail out strategies for perioperative complications are imperative in this higher risk subset of PTE.

CTEPH: Type III Disease Concomitant small vessel disease Pathology: PAH like small vessel arteriopathy Imaging: discordance between hemodynamic and perfusion defects Clinical: hemodynamic progression without new perfusion defects Eur Respir Rev 2013;22:258-264

Balloon Pulmonary Angioplasty

Balloon Angioplasty

Curr Opin Pulm Med 2015, 21:425 431

J Thorac Cardiovasc Surg 2014;148:1005-12