Pulmonary Endarterectomy For Cteph
Pulmonary Endarterectomy (PEA) is a surgical procedure performed to remove organized clots (thrombi) from the pulmonary arteries. It is the definitive treatment for Chronic Thromboembolic Pulmonary Hypertension (CTEPH), a form of pulmonary hypertension caused by chronic blood clots in the lungs that obstruct blood flow and increase blood pressure in the pulmonary arteries.
Indications:
- Patients diagnosed with CTEPH who have accessible thromboembolic disease in the pulmonary arteries.
- Persistent pulmonary hypertension despite adequate anticoagulation therapy.
- Symptoms of right heart failure, such as shortness of breath, fatigue, and swelling in the legs.
Preoperative Evaluation:
- Detailed imaging studies such as pulmonary angiography, CT pulmonary angiography (CTPA), and ventilation-perfusion (V/Q) scan to assess the location and extent of the thrombi.
- Right heart catheterization to measure pulmonary artery pressures and evaluate heart function.
- Assessment of the patient's overall health and suitability for surgery, including lung function tests and evaluation of comorbidities.
Surgical Procedure:
- Anesthesia: General anesthesia is administered.
- Incision: A median sternotomy (incision in the center of the chest) is made to access the heart and lungs.
- Cardiopulmonary Bypass: The patient is placed on a heart-lung machine to maintain circulation and oxygenation during the procedure.
- Hypothermic Circulatory Arrest: The body is cooled to reduce metabolic demands and protect the brain while blood circulation is temporarily stopped.
- Endarterectomy: The surgeon carefully removes the organized thrombi from the pulmonary arteries. This involves delicately peeling away the layers of the clot from the arterial walls.
- Rewarming and Weaning from Bypass: The patient is gradually rewarmed, and normal circulation is restored. The heart-lung machine is slowly weaned off.
- Closure: The sternotomy is closed, and the patient is moved to the intensive care unit (ICU) for recovery.
Postoperative Care:
- Intensive monitoring in the ICU to manage blood pressure, fluid balance, and oxygenation.
- Pain management and respiratory support as needed.
- Anticoagulation therapy to prevent new clot formation.
- Regular follow-up with imaging and pulmonary function tests to assess the success of the surgery and monitor for any complications.
Benefits:
- Significant improvement in symptoms and quality of life.
- Reduction in pulmonary artery pressures and right heart strain.
- Improved exercise capacity and overall functional status.
- Potentially curative for CTEPH, with long-term survival benefits.
Risks and Complications:
- Bleeding and infection.
- Reperfusion pulmonary edema (fluid accumulation in the lungs after restoring blood flow).
- Stroke or neurological complications due to hypothermic circulatory arrest.
- Right heart failure or other cardiac complications.
- Residual pulmonary hypertension if not all thrombi can be removed.
Outcomes:
- PEA is considered the gold standard treatment for CTEPH and has a high success rate when performed at experienced centers.
- Most patients experience substantial relief of symptoms and improvement in hemodynamics.
- Long-term prognosis is favorable with proper postoperative management and follow-up.