title: Pulmonary endarterectomy for distal chronic thromboembolic pulmonary hypertension.
abstract: OBJECTIVE
  Chronic thromboembolic pulmonary hypertension can be cured by pulmonary endarterectomy. Operability assessment remains a major concern, because there are no well-defined criteria to discriminate proximal from distal obstructions, and surgical candidacy depends mostly on the surgeon's experience. The intraoperative classification of chronic thromboembolic pulmonary hypertension describes 4 types of lesions, based on anatomy and location. We describe our recent experience with the more distal (type 3) disease.
  
  
  METHODS
  More than 500 pulmonary endarterectomies were performed at Foundation I.R.C.C.S. Policlinico San Matteo (Pavia, Italy). Because of recent changes in the patient population, 331 endarterectomies performed from January 2008 to December 2013 were analyzed. Two groups of patients were identified according to the intraoperative classification: proximal (type 1 and type 2 lesions, 221 patients) and distal (type 3 lesions, 110 patients).
  
  
  RESULTS
  The number of endarterectomies for distal chronic thromboembolic pulmonary hypertension increased significantly over time (currently ∼37%). Deep venous thrombosis was confirmed as a risk factor for proximal disease, whereas patients with distal obstruction had a higher prevalence of indwelling intravascular devices. Overall hospital mortality was 6.9%, with no difference in the 2 groups. Postoperative survival was excellent. In all patients, surgery was followed by a significant and sustained improvement in hemodynamic, echocardiographic, and functional parameters, with no difference between proximal and distal cases.
  
  
  CONCLUSIONS
  Although distal chronic thromboembolic pulmonary hypertension represents the most challenging situation, the postoperative outcomes of both proximal and distal cases are excellent. The diagnosis of inoperable chronic thromboembolic pulmonary hypertension should be achieved only in experienced centers, because many patients who have been deemed inoperable might benefit from favorable surgical outcomes.
authors.affiliation: Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy; Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy. Electronic address: darmini@smatteo.pv.it.
authors.forename: Andrea M
authors.initials: AM
authors.lastname: D'Armini
authors.affiliation: Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Morsolini
authors.affiliation: Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy; Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Mattiucci
authors.affiliation: Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy; Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Valentina
authors.initials: V
authors.lastname: Grazioli
authors.affiliation: Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Pin
authors.affiliation: Institute of Radiology, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Adele
authors.initials: A
authors.lastname: Valentini
authors.affiliation: Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Silvaggio
authors.affiliation: Service of Biometry and Clinical Epidemiology, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Catherine
authors.initials: C
authors.lastname: Klersy
authors.affiliation: Institute of Radiology, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Dore
mesh_terms: D000368:Aged; D062186:Arterial Pressure; D002908:Chronic Disease; D004691:Endarterectomy / Q000009:adverse effects / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006976:Hypertension, Pulmonary / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D016016:Proportional Hazards Models; D011651:Pulmonary Artery / Q000503:physiopathology / Q000601:surgery*; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome