Reverse Right Ventricular Remodeling after Pulmonary Endarterectomy
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Objective: Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH). Bilateral lung transplantation (BLTx) is indicated only in few cases when PEA is not feasible. Right ventricular remodeling and dysfunction are major features of PEA candidates and are often associated with functional tricuspid regurgitation (TR). The present study evaluated the capability of the right ventricle to recover normal geometry and function after PEA.
Methods: From 12/2000 to 8/2003, 45 consecutive PEAs were performed. The right ventricle (RV) was studied by magnetic resonance imaging (MRI), echocardiography (ECHO), and right heart catheterism (CATH). The full set of preoperative data was available for 37 candidates, with complete follow-up for 33 patients at 3 months, 32 patients at 1 year, and 9 patients at 3 years.
Results: In-hospital mortality was 2.7% (1/37), 1patient had BLTx on post-operative day 4. Two patients abandoned the study, 1 late death occurred for cancer 1 year postoperatively. PEA resulted in significant relief of pulmonary hypertension. Imaging revealed early recover of normal RV geometry and size and disappearance of clinically significant TR with no late changes. RV function showed steady recovery with mid-term improvement.
Conclusions: PEA results in significant relief of pulmonary hypertension. Early and mid-term results demonstrate full recovery of normal RV geometry and function after PEA. TR also rapidly regresses with no need of surgical intervention. PEA cures CTEPH safely and effectively and should be preferred over BLTx whenever possible.
MRI, ECHO, and CATH data | Preoperative
n = 37 | 3 Months
n = 33 | 1 Years
n = 32 | 3 Years
n = 9 | p Value* |
MRI
RV-EDV (ml)
RV-ESV (ml)
RV-WT (mm)
REF (%) | 112.5±39.9
80.0±33.3
8.4±1.3
29.9±11.4 | 72.8±20.4
45.1±18.7
6.9±1.2
38.9±11.7 | 74.0±16.6
41.7±13.3
6.2±0.8
43.8±9.9 | 73.1±29.4
36.0±11.9
5.6±0.8
50.3±5.9 | <0.001
<0.001
<0.001
<0.001 |
ECHO
RV-EDD (mm)
FAS (%)
TR (% pts): 0-1
2-3 | 40.2±8.7
24.3±9.8
21.6
78.4 | 30.6±5.3
32.6±11.0
82.4
17.6 | 31.3±4.7
36.2±11.0
75.8
24.2 | 30.6±5.4
41.0±5.9
75
25 | <0.001
<0.001
<0.001 |
CATH
PVR (d*cm*sec-5)
CI (l/min/m2)
RAP (mm Hg) | 1143.0±475.6
1.7±0.4
7.4±6.0 | 314.7±202.0
2.6±0.5
1.7±2.0 | 347.1±276.0
2.5±0.4
2.7±3.4 | 216.6±129.4
2.36±0.3
1.25±2.1 | <0.001
<0.001
<0.001 |
| RV right ventricle; EDV End Diastolic Volume; ESV End Systolic Volume; WT Wall Thickness; REF Right Ejection Fraction; EDD End Diastolic Diameter; FAS Fractional Area Shrinkage; TR Tricuspid Regurgitation: 0-1= absent/mild, 2-3= moderate/severe; PVR Pulmonary Vascular Resistance; CI Cardiac Index; RAP Right Atrial Pressure. *pre-operative vs. post-operative values. |
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