Dr. R. Novaconi, Dr. D. Nica, Dr. V. Angelescu, Dr. C. Jusca Prof. Dr. M. Gaspar.

Pulmonary tromboendarterctomy is an open-heart procedure performed for patients with chronic pulmonary hipertension due to reccurent or chronic emboly in the pulmonary artery.

PTEs involve a full cardiopulmonary by-pass (CPB),

deep hypothermia and full cardiac arrest.

The most challenging part of the surgery is finding

the optimal plane to dissect the pulmonary artery.

Usually an inferior vena cava filter inserted.
PTE procedures are performed only in specialised

medical centers.
A PTE has significant risk; mortality is typically 5%.

INSTITUTE OF CARDIOVASCULAR MEDICINE TIMISOARA, ROMANIA

----- COLLABORATION -----CARDIOTHORACIC SURGERY DEPARTMENT, VIENNA, AUSTRIA

Objectives:
Analysis of the outcomes for patients who undervent pulmonary tromboendarterectomy procedure at Institute of Cardiovascular Diseases Timisoara Time range: 2003-present.

Materials and methods:

male: female ratio

Total procedures: 26 Males: 18 Females: 8

male 69%

female 31%

Age range: 23-86 yrs

9 8 7 6 5 4 3 2 1 0 21-30 31-40 41-50 51-60 61-70 71-80 81-90

Medium Age

Most patients presented:

-mild/severe dyspneea -hemorrhagic cough -thoracic pain (not angina-like) -deep venous thrombosis -history of reccurent pulmonary thromboembolism -history of stroke -smoking habbit -history of birth control pills (females)

Investigations: Chest X-ray

-enlarged heart diameter -possible pleural collection -possible visualisation of enlarged pulomary artery or absence of pulmonary artery (thrombosis) -possible lung atelectasis

Echocardiography: LA -enlarged right heart cavities -pulmonary hipertension Ao RA (medium/severe) PA -tricuspid valve insuficiency -pulmonary valve insuficiency Tr. -possible paradoxal movement of interventricular septum -possible visualisation of thrombus in PA or RA EKG: -sinus tahycardia, right bundle block, QRS axis with right deviation.

Right Heart Angiography -visualisation of trombus in PA -oclusion of pulmonary artery or branches . (also associated left heart angiography for coronary artery disease)

Computer-Tomography:

-evidentiation of trombus in pulmonary artery and its branches -possible pleural collection -possible lung condensation areas

Spirometry -obstructive/mixt ventilatory disfunction -hypoxemia -hypocapnia - VEMS Arterial gazometry -hypoxemia, hypocapnia

Results:

8 patients presented post-op complications: -cardiac tamponade- reintervention -hemorrhage-reintervention -mediastinitis-reintervention-deceased -pleuresia -ruptured PA-massive bleeding-deceased -respiratory failure -2 cases of atrial fibrillation

3 patients had associated procedures performed:

-ASD closure and deviation of partial abnormal pulmonary venous drainage -aortic valve replacement- St. Jude 23 mm -right atrium thrombus extraction

Surgery is the only potentially curative therapy for chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary thromboendarterectomy is the surgical procedure of choice. The decision to proceed to pulmonary thromboendarterectomy is based upon the following criteria: -NYHA III-IV class -preoperative pulmonary vascular resistance (PVR) of greater than 300 dyn s cm5 -surgical accessibility of the thrombi; -presence of hemodynamic and/or ventilatory impairment; -impact of the patients comorbidities on the risks of the surgery; -willingness and motivation of the patient to undergo surgery

Discussions:
Chronic thromboembolic pulmonary hipertension is a

under-diagnosed condition due to lack of awarness, fatal if not treated Pulmonary thromboendarterectomy involves cardiopulmonary by-pass, and periods of hypothermic circulatory arrest The purpose of inferior vena cava filter insertion is to protect patients from recurrent pulmonary emboli both during the high-risk perioperative period and long-term

Conclusions:
PTE is a complex surgical procedure, performed in few specialised medical centers. The mortality rate seems to be correlated with association of chronic pulmonary hipertension with other conditions, such as congenital cardiac malformations, coronary disease or valvular disease.