pulmonary endarterectomy: the pavia experience
DESCRIPTION
PULMONARY ENDARTERECTOMY : THE PAVIA EXPERIENCETRANSCRIPT
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
Andrea M D’Armini, MD, FCCP
Division of Cardiac SurgeryUniversity of Pavia School of MedicineFoundation I.R.C.C.S. San Matteo HospitalPavia - Italy
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
INTRODUCTION
• Chronic thromboembolic pulmonary hypertension (CTEPH) represents the only type of pulmonary hypertension surgically treatable, in the majority of cases, without transplant
• This life-saving conservative surgery is called pulmonary endarterectomy (PEA)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
INTRODUCTION
• Elective surgery, non donor-dependent• No “transplant window” to be considered• Age is not a contraindication• Lower post-operative complications
– early (acute graft failure, acute rejection, infections)– late (BOS, neoplasms, infections)
• Outcome– post-operative long term survival– quality of life (back to normal)– steady functional improvement
PEA vs. LTx
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
EPIDEMIOLOGY
• Epidemiologic data: in Italy ≈ 65.000 cases / year of acute symptomatic pulmonary embolism (PE)
• Prevalence of CTEPH in pts surviving an acute PE (≈ 80 %) is calculated between 0.5% – 3.8%
→ up to 2.000 new cases / year
• Considering asymptomatic pulmonary embolism and misdiagnosed pulmonary embolism, the true incidence of CTEPH may be even greater
• Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg 2000; 37:165-252• Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001; 345:1465-72• Pengo V, Lensing AV, Prins MH, Marchiori A, Davidson BL, Tiozzo F et al. Incidence of chronic thromboembolic pulmonary
hypertension after pulmonary embolism. N Engl J Med 2004; 350:2257-64
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CURRENT SITUATION
• CTEPH is still under-diagnosed and nowadays only few physicians are aware of the surgical procedure called PEA
• For all these reasons about 8000 PEA have been performed worldwide so far with ≈ 30 % of all cases carried out by the San Diego Group
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
NATURAL HISTORY
• Pulmonary embolism (symptomatic / asymptomatic)
• “Honeymoon” period: months / years
• Hypertensive remodeling of the patent pulmonary vascular bed (Eisenmenger-like)
• Right ventricle hypertrophy with progressive right heart deterioration right failure
• Left ventricle compression with left heart functional impairment
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
GENERAL CONDITIONS
• Low cardiac output with dyspnea, cough, cyanosis, hepatomegaly, ascites, lower limb edema, syncope, hemoptysis and interscapular olosystolic murmur
• Hypoxemia with exercise, sometimes at rest also
• Frequent positive anamnesis for deep venous thrombosis and / or coagulative and immunologic disorders
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• A PERMANENT INFERIOR VENA CAVA FILTER was placed before PEA in the majority (376/410) of patients
• Lifelong oral anticoagulation was prescribed after PEA
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
MARKED THROMBOPHILIA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REFERENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REFERENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REFERENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REFERENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
INDICATIONS FOR SURGERY
• The indications for the surgical treatment of these patients are based on
CLINIC
HEMODYNAMIC
• The indications for the type of surgery are based on
ANATOMY
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CLINIC
• Patients must be in NYHA functional class III or IV
• Full anticoagulation for at least 3 months
• Some Authors (we too) recently have performed PEA even in NYHA class II patients, given the natural history of the disease
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
HEMODYNAMIC
• Pulmonary hypertension (mPAP 25 mmHg)• Causing low cardiac output
• Resulting in calculated pulmonary vascular resistances (PVR) > 300 dyne*sec*cm-5
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
HEMODYNAMIC
• In some cases this calculation [PVR = (mPAP – Wedge) / CO * 80] could result in a value < 300 dynes*sec*cm-5 due to a partially maintained CO ( 3.5 L/min) or for a inaccurate measurement of wedge pressure (high value for extensive collateral bronchial arteries flow)
• In these cases the leading variable is the degree of pulmonary hypertension (mPAP 25 mmHg at rest)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ANATOMY
• The surgical treatment depends on the localization of the lesions in the pulmonary arterial branches
• Lesions can be classified asPROXIMAL
DISTAL
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PROXIMAL LESIONS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
M.B. – 62 yrs M – Jul 2001 – PEA #64
Perfusion and ventilation scan
Pulmonary angiogram
Hemodynamic
mPAP 67CI 1.6PVR 1766
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
DISTAL LESIONS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
S.S. – 31 yrs M – Sep 2002
Perfusion and ventilation scan
Pulmonary angiogram
Hemodynamic
mPAP 50CI 1.8PVR 1120
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Growing single surgeon’s experience due to learning curve
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
OPERABILITY ASSESSMENT
Which lesions have to be considered as inoperable?
• Different operability assessments from different Centers
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
BACKGROUND
• PEA is the treatment of choice for patients with CTEPH• About only 10-15 Centers worldwide are performing PEA
on a routine basis• In expert hands, mortality ranges between 5% and 12%
and technical failure is below 8%• Early hemodynamic results
are known to be excellent incase of successful operation
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REFERENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• National referral program
• Begin: April 1994
• To date: 410 PEAs performed
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
OUR PROGRAM
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
62113
128
22
2119
30
8
57
245
20 193
6
19
Pts coming from outside Italy- Greece 1- Kosovo 1- U.S.A. 1- Uganda 1
2
3
Pavia
≤ 15 pts
16 – 30 pts
≥ 31 pts
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PATIENTS’ REFERRALOF 410 PEAs
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
NUMBER OF PEAs / YEAROF 410 PEAs
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSOF 410 PEAs
2009-2011: 60 PEAs / yr
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSOF 410 PEAs
1994-2007 (14 yrs): 174 PEAs
2008-2011 (4 yrs): 211 PEAs
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSNEW EVALUATIONS
54
108
0
20
40
60
80
100
120
2004 2010
Pat
ien
ts
+ 100%
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSDIAGNOSTIC ACCURACY
34
82
20 260
10
20
30
40
50
60
70
80
90
2004 2010
Pat
ien
ts
IPCTE
Other
63%
76%
+ 13%
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSOPERABILITY RATE
25
73
9 90
10
20
30
40
50
60
70
80
2004 2010
Pat
ien
ts
Operable
Inoperable
74%
89%
+ 15%
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AMOUNT OF PATIENTSPEAs PERFORMED
22
65
0
10
20
30
40
50
60
70
2004 2010
PE
As
+ 195 %
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA EXPERT CENTER
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA EXPERT CENTER
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
MAIN WORLD PEA CENTERS
Paris, France≈100 PEAs / year
NATIONAL REFERRAL PROGRAM FOR EXCELLENCE
Cambridge, UK≈80 PEAs / year
NATIONAL REFERRAL PROGRAM BY LAW
Pavia, Italy≈60 PEAs / year
MORE THAN ONE PROGRAM
Bad Nauheim, Germany≈50 PEAs / year
MORE THAN ONE PROGRAM
San Diego, California, USA≈130 PEAs / year
NATIONAL REFERRAL PROGRAM FOR EXCELLENCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA POPULATIONOF 410 PEAs
Age 58 16 (11 84) years
Gender 195 M – 215 F
NYHA class 43 II – 188 III – 179 IV
Length III / IV 19 23 months
Urgent / Emergent 81 / 410
Oxygen therapy 194 / 410
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ECHOCARDIOGRAPHY
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CARDIAC MAGNETIC RESONANCE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
MODIFIED BRUCE TESTOF 410 PEAs
Steps Walking distance
No (Pa O2 < 60) 42.6% 183 ± 160 (8 – 852) meters
Step 0 - ½ 47.5%
Step 1 - 2 8.2%
Step 3 - 4 1.6%
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Median sternotomy• Cardio Pulmonary Bypass• Moderate hypotermia (24
°C)
• Circulatory arrest (7 min)• Reperfusion period (5 min)• Bilateral
J Thorac Cardiovasc Surg 1993;106:116-27
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Intra-wall dissection• Peripheral extension• Explore all branches
J Thorac Cardiovasc Surg 1993;106:116-27
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
SURGICAL TIPS
• Deep-moderate hypothermic circulatory arrest- meticulous dissection into a bloodless field (for optimal hemodynamic result)
• Unclamped aorta- avoidance of aortic manipulation (reduction of cerebral events)
• Hypothermic cardiac protection- ventricular fibrillation induced by hypothermia- ventricular fibrillation induced by device (fibrillator) - avoidance of cardioplegia administration
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Changing features of CTEPH patients
- population is rapidly aging, and an increasing number of elderly patients are referred for PEA
- due to the continuous surgeon’s learning curve, the crucial border between operable and inoperable patients has been pushed more and more distally over time
CTEPH patients are getting more frail and complex
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
SURGICAL TIPS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT• Original San Diego technique
- a single (20 min) deep hypothermic (18° C) total circulatory arrest for each side
• Recent advances
- short periods (5 – 7 min) of intermittent moderate hypothermic (24 ° C) circulatory arrest
- followed by short periods of reperfusion ( 5 min)
- with cerebral near-infrared spectroscopy (NIRS) monitoring
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CEREBRAL PROTECTION STRATEGYNIRS MONITORING
Near-InfraRed Spectroscopy
0
20
40
60
80
100
9.03
.15
9.20
.53
9.39
.01
9.56
.48
10.1
4.55
10.3
3.14
10.5
1.24
11.0
9.32
11.2
9.10
11.4
7.13
12.0
5.15
12.2
3.17
12.4
1.20
12.5
9.23
13.1
7.26
13.3
5.30
13.5
3.34
14.1
1.37
14.2
9.39
14.4
7.42
15.0
5.45
15.2
3.48
15.4
1.52
15.5
9.54
16.1
8.27
16.3
6.26
16.5
4.23
17.1
2.20
Time
SrO
2
Right channel
Left channel
CPB start
Patient’s cooling
Pre-HCA baseline
HCA maximum drop
Reperfusion
Changing PEA side
End of PEA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT• 1st step
- short periods (10 – 15 min) of intermittent deep hypothermic (18 ° C) circulatory arrest followed by short periods of reperfusion ( 5 min) with cerebral near-infrared spectroscopy (NIRS) monitoring
• 2nd step
- moderate (24 ° C) instead of deep hypothermic circulatory arrest
• 3rd step
- shorter periods (5 – 7 min) of intermittent circulatory arrest
• to reduce invasiveness• to get more time to perform PEA in a bloodless surgical
field
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENTOF 410 PEAs
• Group A (83 pts)
- original San Diego technique (but unclamped aorta)
• Group B (70 pts)- short periods (10 – 15 min) of intermittent deep hypothermic (18 ° C)
circulatory arrest followed by short periods of reperfusion ( 5 min) with cerebral near-infrared spectroscopy (NIRS) monitoring
• Group C (91 pts)
- moderate (24 ° C) instead of deep hypothermic circulatory arrest
• Group D (166 pts)
- shorter periods (5 – 7 min) of intermittent circulatory arrest
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT
Postoperative respiratory function and outcome
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CPB MANAGEMENT
Despite
- patients are getting older
- PEA surgery has become more complex due to Jamieson type III lesions
- moderate (24° C) instead of deep (18° C) hypothermia
- longer total circulatory arrest time
Intermittent circulatory arrest under NIRS monitoring
seems to enhance cerebral protection during PEA
allowing for safe prolonged total circulatory arrest time
and improving postoperative outcomes
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
SURGICAL INSTRUMENT
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
E.L. – 38 yrs M – Dec 1999 – PEA #42mPAP 43 20 (-53%)CO 3.3 6.9 (+109%)PVR 994 220 (-78%)
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
TYPICAL SURGICAL SPECIMENS
P.A. – 66 yrs M – Jun 2001 – PEA #60mPAP 50 25 (-50%)CO 2.6 4.4 (+69%)PVR 1385 364 (-74%)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
DISTAL LESIONSJAMIESON TYPE IIILEARNING CURVE
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE I vs. TYPE II vs. TYPE III
L.M.E.L. - 65 yrs M - Oct 2004 - PEA #119mPAP 39 19 (-51%)CO 4.4 5.4 (+23%)PVR 665 222 (-66%)
G.A.C. - 52 yrs F - Jul 2003 - PEA #96mPAP 48 27 (-44%)CO 2.1 4.2 (+100%)PVR 1638 381 (-77%)
B.A. - 43 yrs F - May 2009 - PEA #233mPAP 49 19 (-61%)CO 3.3 5.0 (+52%)PVR 1067 224 (-79%)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192 204 216 228
Months
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0C
umul
ativ
e P
ropo
rtio
n S
urvi
val
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CUMULATIVE PROPORTION SURVIVINGOF 410 PEAs
Hospital mortality
Global 39/410 (9.5%)WHO II 0/43 (0.0%)WHO III 12/186 (6.5%)WHO IV 27/181 (14.9%)
Jan 08 – May 12 18/236 (7.6%)Jan 11 – May 12 6/82 (7.3%)
296 238 182 140 119 103 88 68 50 42 32 31 24 18 9 3 3 2
90.0%88.3%
87.1% 86.4%84.8%
83.0%81.1%
79.5% 77.6% 74.7%
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
FOLLOW-UP
In literature few data are reported on mid- and long- term cardiopulmonary function, particularly on exertion, and on clinical outcomes after PEA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
FOLLOW-UP TIMING
• All pts underwent follow-up evaluation at:– discharge (at this interval NYHA class, lung function, and exercise
tolerance are excluded because pts are to close to the surgical procedure)
– 3th month– yearly for 5 years– 7th, 10th and 15th year (10 controls)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
FOLLOW-UP DATA
• Seventeen of 368 pts (4.6%) do not participate to the long-term follow-up study since the beginning (2/4 pts referred from outside Italy) or at various intervals
• For these pts we obtain data on survival and WHO functional class annually by scheduled phone-calls
• All the other pts (95.4%) actively participate to the study
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
NYHA FUNCTIONAL CLASS
NYHA Functional Class
0
10
20
30
40
50
60
70
80
90
100
Pre-op 3 mesi 1 anno 3 anni 5 anni 7 anni 10 anni
Follow-up
% p
ati
ents
I -I I
I I I -IV
Pre-op 3m 1y 3y 5y 7y 10y
p < 0.01
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
mean PULMONARY ARTERY PRESSURE
mean Pulmonary Arterial Pressure
0
10
20
30
40
50
60
Pre-op Dimiss 3 mesi 1 anno 3 anni 5 anni 7 anni 10 anni
Follow-up
mm
Hg
p < 0.01
Pre-op disch 3m 1y 3y 5y 7y 10y
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY VASCULAR RESISTANCES
Pulmonary Vascular Resistances
0
200
400
600
800
1000
1200
Pre-op Dimiss 3 mesi 1 anno 3 anni 5 anni 7 anni 10 anni
Follow-up
dyne*se
c*cm
-5
p < 0.01
Pre-op disch 3m 1y 3y 5y 7y 10y
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ECHOCARDIOGRAPHYBefore PEA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ECHOCARDOGRAPHYFirst echo after PEA – POD #9
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ECHOCARDIOGRAPHY3-months FUP after PEA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CARDIAC MAGNETIC RESONANCEBefore PEA First CMR after PEA – POD #6
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CARDIAC MAGNETIC RESONANCE4-years FUP after PEAFirst CMR after PEA – POD #6
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
REVERSE RIGHT VENTRICULAR REMODELING
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING
REVERSE RIGHT VENTRICULAR REMODELING
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING
REVERSE RIGHT VENTRICULAR REMODELING
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING
REVERSE RIGHT VENTRICULAR REMODELING
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
ARTERIAL OXYGEN PARTIAL PRESSURE
Arterial Oxygen Partial Pressure
0
10
20
30
40
50
60
70
80
90
100
Pre-op 3 mesi 1 anno 3 anni 5 anni 7 anni 10 anni
Follow-up
mm
Hg
p < 0.01
Pre-op 3m 1y 3y 5y 7y 10y
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
MODIFIED BRUCE TEST
Modified Bruce Test
0
100
200
300
400
500
600
700
800
900
1000
Pre-op 3 mesi 1 anno 3 anni 5 anni 7 anni 10 anni
Follow-up
met
ers
p < 0.01
Pre-op 3m 1y 3y 5y 7y 10y
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
RESULTS• The majority of pts experienced dramatic improvement in
pulmonary hemodynamics after PEA
• After PEA the decrease in pulmonary artery pressure is immediate (in O.R.) and associated with complete recovery of RV morphology (at discharge)
• The functional results also show a progressive good recovery over a longer time (about years)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
RESULTS
• About 5% of our pts failed to showed a decrease > 20% in PVR compared to pre-operative value
• About 8-10% of our pts showed a new increase in pulmonary pressure after PEA over time
• The reason could be a secondary small vessel arteriopathy (Eisenmenger-type syndrome) in the non-obstructed segments of the lungs already present at the time of PEA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CONCLUSION
• Poor survival rate of untreated pts (10% 5-yrs survival if mPAP 50 mmHg), low mortality rate after PEA and good mid- and long- term results confirm PEA as the procedure of choice for operable CTEPH pts
• The improvement of functional capacity strictly depends on the hemodynamic changes after PEA
• When CTEPH is diagnosed, given the natural history of the disease, patients should be referred for surgery even when in NYHA functional class II
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMYIN THE ELDERLY
EXTENSION OFSURGICAL CRITERIA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AGE
Patients older than 70 years
• Apr 1994 – Dec 2002 → 10.8 % (9/83)
• Jan 2003 – May 2012 → 32.1% (105/327)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
AGE
0%
20%
40%
60%
80%
100%
1994-1998 1999-2003 2004-2008 2009-2011
>= 70 yrs
< 70 yrs
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
STUDY POPULATION
Two distinct populations were therefore identified according to age (<70 yrs or ≥70 yrs) and described by
– pre-operative variables
– operative and post-operative variables
Apr 1994 – May 2012 → 410 PEAs
296 (72.2%) PEAs performed in patients < 70 years old
114 (27.8%) PEAs performed in patients ≥ 70 years old
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CUMULATIVE PROPORTION SURVIVING
OF 296 vs. 114 PEAs
< 70 yrs >= 70 yrs0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180
Months after PEA
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0P
erc
en
tag
e126 112 101 87 69 53 42 34 30 23 15 9 4 4 2
29 19 15 10 6 4 4 2 2 2 2 1 1
90.92.2
86.93.088.52.689.32.5
85.03.5 85.03.581.25.7
78.06.3 78.06.3
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Age did not affect the efficacy of PEA: PVR dramatically and equally decreased in both groups
• We never considered age as a contraindication to PEA
• However, operative mortality and perioperative morbidity were higher in patients age 70 and older: Gram negative infections and reperfusion edema were more severe in the elderly
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CONCLUSIONS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Compared to young subjects, elderly patients had a higher prevalence of major preoperative comorbidities, were sicker at the time of operation and had a reduced functional reserve of their vital organs
• However, this has to be expected in such patients:– age is a well identified independent risk factor in cardiac surgery– in elderly patients the immune system response is less effective– antibiotic therapy may lead to renal and hepatic impairment,
increasing morbility and mortality
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CONCLUSIONS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
New surgical strategies have been adopted in order to reduce invasiveness in the frail elderly:
– prefer moderate (24-26 °C) to deep (16-18 °C) hypothermia
– perform shorter circulatory arrests (7-9 min vs. 20 min)
– effective prophylaxis of infections (intra-operative BAL)
– refer elderly patients to a rehabilitation Center before PEA to improve their vital organs functional reserve and to gain a better functional status at the time of operation (notably for COPD)
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
CONCLUSIONS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMYIN WHO FUNCTIONAL CLASS II
EXTENSION OFSURGICAL CRITERIA
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
Population
43 PEAs out of 410 (10.5 %) from Apr 1994 to May 2012
Hospital mortality 0 %
Main patients’ features
“couch potatoes” “sportsmen” 53.5 % (23/43) 46.5 % (20/43)
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
Population
Wide spectrum of clinical presentations
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
Results
Postoperative outcome
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
Results
Postoperative outcome
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
• Given the natural history of the disease we perform PEA even in NYHA functional class II patients
• Once CTEPH is diagnosed, there is no reason to delay surgery:
– CTEPH is associated with a progressive vascularremodeling of the unobstructed branches
(Eisenmenger)
– outcome after PEA in NYHA II patients is excellent
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
Results