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First Pulmonary Endarterectomy in Latvia

Andrzej Biederman

Martins Kalejs

Kristaps Sablinskis

Andris Skride

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Conference: 2014 International PHA Conference and Scientific Sessions

Release Date: 06.21.2014

Presentation Type: Abstracts

File Download: 2014 Conference Abstracts - Andris Skride

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Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) and it is used to reduce pulmonary vascular resistance with significant symptomatic and prognostic benefit. The fundamental aim of the surgery is to perform a full endarterectomy i.e. to remove the neointimal layer of the both pulmonary arteries together with the non-resolved thrombus consisting of organized collagen-rich fibrotic areas with partly recanalized regions so this procedure is not an embolectomy or a thrombectomy.

Background: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension (CTEPH) and it is used to reduce pulmonary vascular resistance with significant symptomatic and prognostic benefit. The fundamental aim of the surgery is to perform a full endarterectomy i.e. to remove the neointimal layer of the both pulmonary arteries together with the non-resolved thrombus consisting of organized collagen-rich fibrotic areas with partly recanalized regions so this procedure is not an embolectomy or a thrombectomy.

Even though there are several patients in Latvia needing PEA, this surgery has never been performed here. Thanks to cooperation between Latvia and Poland, first PEA in Latvia was performed in PSCUH on august 2013 on a 31-year-old male with CTEPH.

Methods: The operation was performed via a median sternotomy with hypothermic cardiopulmonary bypass (CPB) at 18 °C. Pulmonary arteriotomies were performed within the pericardium and periods of circulatory arrest were necessary to reduce collateral blood flow from bronchial arteries and allowed a clear field for dissection distally. The endarterectomy plane was raised carefully as it was essential the correct layer to be identified. The dissection proceeded within the superficial media into all the affected segmental and sub-segmental vessels. A cast of the inner layer of the pulmonary arterial tree was then dissected free by eversion moving towards the periphery. After completion of the endarterectomies the patient was rewarmed slowly on full CPB.

Results: The patient was diagnosed with CTEPH on 2010 (mean pulmonary artery pressure 64 mm Hg) patient received treatment with Warfarin and Sildenafil. In 2013, because of progressive worsening of CTEPH, we started collaboration with prof. A. Biederman. Patient’s BNP before the surgery was 871 pg/mL, Echo showed right chamber dilatation and a very high Right Ventricular Systolic Pressure- 110 mm Hg; 6 minute walking test (6MWT) was 75 m. After consulting with prof. Biederman, we came to a conclusion, that PEA for this patient is a life-saving surgery. The procedure was performed successfully, 6 months post-surgery follow-up shows that BNP has dropped to 39 pg/mL, Echo showed, that right chamber has normal volume and function, 6MWT was more than 600 m. The patient’s functional class (NYHA) changed from class IV before PEA, to condition without heart failure 6 months after surgery.

Conclusions: PEA is a complicated surgery that should only be performed in reference centers by experienced surgeons. Because of the good cooperation between Latvian and Polish doctors, this surgery was possible in Latvia and we are planning to continue our collaboration. We can conclude that the first Latvian experience in this field was a success. Acknowledging the need for a better CTEPH patient management, Latvian CTEPH registry has been created.

Type: Case Study