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Surgical Treatment of Pulmonary Embolism and Chronic Thromboembolic Pulmonary Hypertension

Author(s):

Nikolaos Papakonstantinou*, Polydoros Kampaktsis, Filippos-Paschalis Rorris, Ilias Doulamis, Aspasia Tzani, Sotirios Katsaridis and Dimitrios Avgerinos  

Abstract:


Venous thromboembolism clinically presents as deep venous thrombosis or acute pulmonary embolism and is globally recognized as the third most frequent acute cardiovascular syndrome after myocardial infarction and stroke. Although pulmonary embolism does not typically cause severe pulmonary hypertension in the acute setting, thrombus organization and fibrosis can lead to stenosis or obliteration of pulmonary arteries in a minority of patients, which in turn result in severe pulmonary hypertension and right heart failure. This disease is labeled chronic thromboembolic pulmonary hypertension and can occur after a single episode or multiple ones of pulmonary embolism. The cornerstone of pulmonary embolism treatment is medical therapy, whereas systemic thrombolytic therapy has to be considered for patients with hemodynamic instability. Given the current acceptable short-term surgical mortality, the potential of first-line surgical embolectomy as an alternative to medical thrombolysis has gained momentum as far as pulmonary embolism treatment is concerned. In contrast to pulmonary embolism, bilateral complete pulmonary endarterectomy under short deep hypothermic circulatory arrest intervals is the treatment of choice against chronic thromboembolic pulmonary hypertension, given patients’ operability. Pulmonary endarterectomy is suggested in every operable patient when the operation is offered by an experienced multidisciplinary team, including at least one experienced surgeon. Surgical embolectomy should also be limited to large institutions since it also requires an experienced heart team. This review concerns a thorough discussion regarding surgical treatment of pulmonary embolism and chronic thromboembolic pulmonary hypertension. Eligibility criteria, operation-related complications and postoperative outcomes are discussed in detail.

Keywords:

pulmonary embolism, chronic thromboembolic pulmonary hypertension, pulmonary hypertension, pulmonary endarterectomy, embolectomy, right heart failure

Affiliation:

Cardiac Surgery Department. Onassis Cardiac Surgery Center, Athens, Division of Cardiology, New York University Langone Medical Center, New York, Department of Thoracic and Cardiovascular Surgery. Evangelismos General Hospital, Athens, Department of Cardiac Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, Cardiac Surgery Department. Onassis Cardiac Surgery Center, Athens, Cardiac Surgery Department. Onassis Cardiac Surgery Center, Athens



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