Year after year, milestone after milestone, growing expertise in a single-center pulmonary endarterectomy program

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially curable form of pulmonary hypertension when operability is established. Following the establishment of a national pulmonary endarterectomy (PEA) program, in collaboration with an international reference center, we report the extended experience and follow-up (FUP) outcomes of the first 14 consecutive patients (pts) treated at our institution.

Methods

Single-center, prospective, observational study of all consecutive pts selected for PEA after multidisciplinary evaluation in a dedicated CTEPH program. Surgical technique was standardized – all procedures were performed by the same operative team under deep hypothermic circulatory arrest. Clinical, echocardiographic and hemodynamic (HD) data were collected at baseline and FUP. In-hospital, early and late postoperative complications and mortality were analyzed.

Results

Fourteen pts underwent PEA (64% female; mean age 68 years). At baseline, 64% were in WHO functional class (FC) II and in 36% in class III. Preoperative characteristics included median NT-proBNP of 1320 pg/mL, mean 6MWD of 242 m, use of PH-specific therapy in 43%, and long-term oxygen in 29%. Baseline echocardiography showed mean systolic pulmonary artery pressure (sPAP) 78 mmHg, TAPSE 18 mm and TAPSE/sPAP ratio 0.26mm/mmHg. HD evaluation revealed mean mPAP 48 mmHg, PVR 9.8 WU and CI 2.32 L/min/m².

Median cardiopulmonary bypass and cross-clamp times were 269 and 64 minutes, respectively. Median duration of mechanical ventilation was 17h; median ICU and total hospital length of stay were 4 and 8.5 days, respectively. One pt developed reperfusion injury and 2 pts had significant postoperative bleeding. No pt required ECMO or reintervention. In-hospital and 30-day mortality were 0%.

At a median FUP of 150 days, 3 pts died of non–procedure-related causes. Among survivors, WHO FC improved in 91% of pts, with 45% reaching class I. NT-proBNP decreased significantly to a median of 378 pg/mL (p=0.011). Echocardiography showed substantial improvement in sPAP (–33mmHg, p=0.002) and TAPSE/sPAP ratio (+0.19mm/mmHg, p=0.030). Right heart catheterization (available in 3 pts) demonstrated HD cure in 2 (mPAP 14 and 18 mmHg) and mild residual PH in 1 (mPAP 36mmHg with normal cardiac output).

Conclusion

The stepwise expansion of our PEA program has been associated with excellent perioperative safety and meaningful clinical and HD improvement. In this initial series of 14 procedures, standardized pt selection, a dedicated multidisciplinary pathway and sustained collaboration with an experienced center enabled high-quality outcomes in a newly established program. These results support the ongoing development and consolidation of PEA within the national CTEPH care network and highlight the feasibility of building advanced surgical expertise in a single-center setting.For image description, please refer to the figure legend and surrounding text.