Uniportal video-assisted thoracoscopic surgery esophagectomy outcomes in 40 consecutive patients.

OBJECTIVES: Minimally invasive esophagectomy has improved over time becoming faster and less invasive. We have changed our technical approach from multiportal to uniportal video-assisted thoracoscopic surgery (VATS) esophagectomy over the years. In this study, we analysed our results with uniportal VATS esophagectomy technique. METHODS: This study was a retrospective analysis of 40 consecutive patients with the intent to perform uniportal VATS esophagectomy for esophageal cancer between July 2017 and August 2021. Demographic criteria, comorbidities, neoadjuvant therapy, intraoperative data, complications, length of stay, pathological data, 30- and 90-day mortality and 2-year survival data were recorded. RESULTS: Forty patients (21 female) were operated (median age 62.9 [53.5-70.25]). Eighteen patients (45%) received neoadjuvant chemoradiation. The chest part of all cases was started with uniportal VATS and 31 (77.5%) was completed uniportally (34 Ivor Lewis, 6 McKeown). The median thoracic operation time in minimally invasive Ivor Lewis esophagectomy was 90 min (77.5-100). The median time for uniportal side-to-side anastomosis was 12 min (11-16). Five (12.5%) patients had leak, and 4 were intrathoracic. Twenty-eight (70%) patients had squamous cell carcinoma, 11 adenocarcinoma and 1 squamous cell carcinoma with sarcomatoid differentiation. Thirty-seven (92.5%) patients had R0 resection. The mean number of lymph nodes dissected was 24 ± 9.5. Thirty- and ninety-day mortality was 2.5% (n = 1). The mean follow-up was 44 ± 2.8 months. Two-year survival was 80%. CONCLUSIONS: Uniportal VATS esophagectomy is a safe, fast and feasible alternative to other minimally invasive and open approaches. Comparable results to contemporary series are observed in perioperative and oncologic outcomes.

Modification of the Nuss procedure: the crossed bar technique for new subtypes of pectus excavatum.

BACKGROUND: We aim to describe four new subtypes of PE in detail and represent modification of the Nuss procedure called crossed bar technique for their optimum correction with good results. METHODS: 101 patients who underwent crossed bar technique between August 2005 and February 2022 were included into the study. RESULTS: The mean age of the patient series was 21.1 (range 15-38 years) years. Mean Haller index was 3.87. Mean operation duration was 86.84 min. 2 bars were used in 74 (73.3%) of the patients whereas 3 bars were preferred in 27 (26.7%) of them. Mean hospital stay was 4.1 (2-8) days, and all the patients were seen routinely on postoperative follow-up at 1st, 6th, and 18th months. Quality of life questionnaires revealed satisfaction. CONCLUSIONS: Cross bar technique yields satisfactory results for these new subtypes and can be performed safely with good results in these selected group of patients.

The angiogenic gene profile of pulmonary endarterectomy specimens: Initial study.

Objectives: The underlying mechanisms for the development of chronic thromboembolic pulmonary hypertension and prognostic biomarkers are not clear yet. Thus, our aim is to assess and identify new biomarkers for the expression of 84 key genes linked to angiogenesis. Methods: Patients who had levels more than 1000 dynes·sec·cm-5 were included in the test group, and the other patients were included in the control group. Twelve specimens were taken from the patients. RT2 Profiler PCR Array (Qiagen) was used to quantify the expression of the 84 key genes. Results: Eight patients (6 male, 2 female, median age 54.4 ± 13.1 years) who underwent pulmonary endarterectomy were included. Pulmonary vascular resistance improved significantly from 811 ± 390 dyn/s/cm-5 to 413.3 ± 144.9 dyn/s/cm-5 (P < .005). A difference was also detected in median mean pulmonary arterial pressure, which decreased from 49.8 ± 9 mm Hg to 32.62 ± 2.50 mm Hg (P > .005) after surgery. Median length of hospital stay was 11.62 ± 2.97 days. The test group had a distinct pattern of impaired angiogenic and antiangiogenic genes. The expression levels of TGFA, TGFB1, THBS2, THBS1, TGFBR1, SERPINE1, SERPINF1, TGFB2, TIMP2, VEGFC, IFNA1, TNF, CXCL10, NOS3, IGF1, and MMP14 were downregulated in the specimens from the patients who had higher pulmonary vascular resistance values, whereas some genes, including PDGFA, showed upregulation that was statistically nonsignificant in the same group. Conclusions: These results can lead to the development of new markers that could predict adverse outcomes of patients with CTEPH. Identification of new markers that are related to worse outcomes would enable screening patients for early diagnosis and treatment.

Surgical Treatment of Another Sequalae of COVID-19: Post-COVID CTEPH.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is still an ongoing entity and every day we face new sequalae of the disease. We hereby present surgical results of patients who are treated for post-COVID chronic thromboembolic pulmonary hypertension. METHODS: Data were collected among patients who underwent pulmonary endarterectomy and had a diagnosis of post-COVID chronic thromboembolic pulmonary hypertension. All data were retrospectively reviewed from a prospectively conducted database. Operative mortality was described as death in hospital or within 30 days of surgery. RESULTS: Eleven patients (seven males, four females; median age, 52 [22-63] years) were identified. Pulmonary vascular resistance improved significantly from 572 dyn/s/cm-5 (240-1,192) to 240 (195-377) dyn/s/cm-5 (p < 0.005). Significant difference was also detected in median mPAP, as it decreased from 40 mm Hg (24-54) to 24 mm Hg (15-36) following surgery (p < 0.005). Mortality was observed in one patient due to sepsis on the fifth postoperative day. Median time from COVID-19 disease to surgery was 12 months (6-24). Median length of hospital stay of the survivors was 10 days (8-14). CONCLUSION: In the new era of chronic thromboembolic pulmonary hypertension, hybrid approach including surgery, balloon pulmonary angioplasty, and medical treatment has been recommended. pulmonary endarterectomy is still the only curative treatment when the disease is surgically accessible. We hereby report the first publication of post-COVID chronic thromboembolic pulmonary hypertension patients who were surgically treated. As we see a lot of long-term symptoms and clinical manifestations in patients who had COVID-19, we should always remember chronic thromboembolic pulmonary hypertension in the differential diagnosis.

Is There Any Role of Pulmonary Endarterectomy in Pulmonary Arterial Hydatidosis?

BACKGROUND: Hydatid cyst is a zoonosis caused by Echinococcus granulosis. Pulmonary artery involvement is a rare condition. The aim of this study was to review the investigators' experience with the surgical treatment of pulmonary arterial hydatidosis. METHODS: Data were collected prospectively for consecutive patients who underwent pulmonary endarterectomy (PEA) and who had a diagnosis of hydatidosis at or after PEA. RESULTS: A total of 8 patients (2 male and 6 female; mean age, 31.25 ± 13.68 years) with hydatidosis were defined. Only 1 patient presented with hemoptysis, whereas the rest of the patients reported exertional dyspnea as their main symptom. Cardiac hydatidosis associated with pulmonary arterial involvement was noted in 1 patient. The mean time interval for duration of disease was 12 ± 24.29 months before PEA. Mortality was observed in 2 patients as a result of massive hemoptysis in 1 patient and right-sided heart failure in the other. No anaphylactic reaction was observed. Significant difference was detected in mean pulmonary vascular resistance as a decline from 442.38 ± 474.20 dyn/s/cm-5 to 357.25 ± 285.34 dyn/s/cm-5 after PEA (P = .011). Two patients had recurrence of the disease after a median follow-up of 9.1 months All survivors improved to New York Heart Association functional classes I and II. CONCLUSION: Pulmonary arterial hydatidosis may mimic chronic thromboembolic pulmonary hypertension, and in these patients the diagnosis can be made with PEA. Pulmonary endarterectomy may be a therapeutic option for patients who do not respond to medical therapy if the cystic lesions are surgically accessible. PEA should be performed only in expert centers because of the high risk of perioperative morbidity, mortality, and postoperative recurrence.

A Comparative Study on Short-Term Effects of Compression Orthosis and Exercises in the Treatment of Pectus Carinatum: A Randomized Controlled Pilot Feasibility Trial.

INTRODUCTION: Pectus carinatum (PC) is a congenital chest wall deformity which is characterized by the protrusion of the sternum and costal cartilages. Although orthotic and exercise therapies are commonly offered by physicians for PC treatment, there is a lack of evidence on the benefits of exercises and how long the orthosis should be worn. The aim of this study is to investigate the effects and feasibility of custom-made compression orthosis and exercises in the treatment of PC. MATERIALS AND METHODS: Patients with PC aged 7 to 17 years old were randomized into three groups: compression orthosis 23 hours, compression orthosis 8 hours, and control group. All groups received exercises for 1 hour a day for 3 weeks. Additionally, compression orthosis 23 hours group wore the orthosis for 23 hours a day, while compression orthosis 8 hours group wore the orthosis for 8 hours a day. PC protrusion, pressure of correction, thorax lateral and anteroposterior parameters, external chest wall measurements, and Nuss Questionnaire were evaluated before and after the treatment. Also, adverse effects, retention, and compliance were assessed. Feasibility was evaluated by calculating the percentages of recruitment, retention, and safety. RESULTS: The compression orthosis 23 hours group showed greater improvements than the other groups. After treatment, all groups showed significant changes in protrusion, pressure of correction, and external chest wall measurements. Adverse events occurred with similar frequency across groups. Retention percentages did not differ among groups. CONCLUSION: Compression orthosis use for 23 hours can be recommended rather than its use for 8 hours because 23 hours of orthosis use has better correction and similar adverse effects.

Total Rib Resection Via Uniportal Thoracoscopic Approach.

In this report, we present a case specifying the availability of uniportal thoracoscopic resection of a total rib safely without the need for conventional thoracotomy. The favorable outcome of this case suggests that the uniportal thoracoscopic technique described here is a safe and successful approach for resection of costal lesions with good cosmetic results. To our knowledge, this is the first case reporting the entire rib resection via uniportal thoracoscopic approach.

Minimally Invasive Repair of Pectus Carinatum.

BACKGROUND: The second most common deformity of the anterior chest wall, pectus carinatum, is a diverse deformity that has been largely managed using open techniques. This study reviews clinical experience with a newly designed bar for minimally invasive repair of pectus carinatum. METHODS: We reviewed the records of all patients recorded in our Chest Wall Deformities Clinical Database. Between January 2006 and November 2016, minimally invasive repair of pectus carinatum was performed in 172 patients. All met the criteria of a "compression test" of 10 to 25 kg/cm2. The mean age was 17.3 years, and 22.7% had a positive family history of a congenital chest wall deformity. Symmetric and asymmetric deformities were treated. During our study period, we designed 4 different bar configurations and their related stabilizers. All patients are assessed every 3 to 6 months. After 2 to 3 years of follow-up, the bar and the stabilizers are removed. RESULTS: Of 172 patients, 97.1% tolerated the procedure very well. The operation was a mean length 76.6 minutes. Average blood loss was 40 mL. Mean hospital length of stay was 3.7 days. Complications included pneumothorax, wire breakdown/rib cut, wound infection, severe pain, skin hyperpigmentation, nickel allergy, and overcorrection leading to excavatum. Patients returned to routine activity in 10 to 14 days. With a mean follow-up of 29.8 months in bar removal patients, 130 of 172 (93.8%) reported excellent results. CONCLUSIONS: Minimally invasive repair of pectus carinatum with the technically modified fourth-generation bar and its securing system has advantages of low morbidity, short hospital stay, and excellent cosmetic results, even in asymmetric cases.

Risk of serious perioperative complications with removal of double bars following the Nuss procedure.

Objectives: The aim of this study is to present our experience with Nuss bar removal and evaluate potential risk factors. The Nuss procedure requires an operation to remove the bar 2-3 years after the initial correction. Although removal of the bar is generally believed to be safe, perioperative complications including major bleeding can occur. Methods: All cases involving removal of the Nuss bar done since April 2007 were recorded in a prospective database. Data were collected on the amount of blood loss, the number of diagnostic interventions, operative management and postoperative course. Results: Of a total of 246 (162 with single bars, 80 with double bars, 4 with triple bars) cases, 43 patients (17.5%) experienced perioperative complications. Five patients underwent secondary postoperative interventions; one patient required same-session emergency video-assisted thoracic surgery (VATS) due to major bleeding. Patients who had complications were significantly older than patients with no complications (20.5 ± 6.5 years vs 17.2 ± 5.9 years, P = 0.002). People having double bars removed were significantly more likely to have perioperative complications (12% vs 27%, P = 0.03) and complications requiring secondary interventions (n = 1 for a single bar, n = 5 for double bars, P = 0.01). Conclusions: Major complications after removal of the Nuss bar occur with some frequency. Although the double-bar removals in our cohort were associated with major complications, the reasons are poorly understood. Immediate management of the complications may require multidisciplinary care. Multicentric pooling of cases is needed for better risk stratification.

Previously Complicated Nuss Procedure Does Not Preclude Blind Removal of the Bar.

BACKGROUND: Nuss procedure has become the procedure of choice for well-selected patients with pectus excavatum. Perioperative complications may pose difficulty during the subsequent bar removal due to adhesions and tissue plane disruptions during the initial surgery and repair. This report describes bar removal experience in patients whose Nuss procedures were complicated by cardiac injury, pericardial breach, and lung parenchyma/diaphragm injury during the initial procedure. METHODS: A total of 529 patients who underwent Nuss procedure between 2007 and 2014 were recorded in a prospective database. Twenty patients with complications (cardiac injury [n = 1], pericardial breach [n = 3], and lung parenchyma/diaphragm injury [n = 16]) were identified. All bars were removed via subcutaneous tissue dissection, without intrathoracic visualization. RESULTS: Average duration of bars was 36 months (±16 months). All bar removal procedures were completed without any need for extra interventions with negligible blood loss. Eighteen patients were able to be discharged within 2 postoperative days. CONCLUSION: Blind bar removal in patients with previously complicated Nuss procedure seems safe and no other interventions (videothoracoscopy, subxiphoid incision, etc.) during bar removal seem to be necessary.

Intrauterine diagnosed sternal cleft patient and her management.

Sternal cleft is a rare chest wall deformity. It can be diagnosed in the intrauterine stage with ultrasonography. Newborn period is the optimal time for the surgical correction of sternal cleft, due to the elasticity of the sternum and minimal compression of underlying structures. Here we reported a newborn patient with sternal cleft which has been operated 5 days after labor. Good surgical outcome and long-term results were accomplished.

Feasibility and Complications in Concomitant Lung Resection With Minimally Invasive Repair of Pectus Excavatum.

Minimally invasive repair of pectus excavatum (MIRPE) is the procedure of choice in experienced centers and can be offered in combination with other thoracic procedures. Between 2001 and 2013, 3 cases involving MIRPE and lung surgery were done in our clinic. While postoperative course of 2 procedures (MIRPE and video-assisted thoracoscopic surgery [VATS] segmentectomy and MIRPE and VATS bullectomy) were uncomplicated, the MIRPE and VATS lung biopsy patient developed major complications arising from prolonged air leak and was ultimately managed with an Eloesser flap. In carefully selected cases, simultaneous lung surgery and MIRPE can be done safely but problems of lung reexpansion, long-term drainage, and infection should be kept in mind.

Validity and reliability of the Turkish version of the nuss questionnaire modified for adults.

BACKGROUND: Pectus excavatum (PE) is the most common chest wall deformity. The Nuss Questionnaire modified for Adults (NQmA) is a disease-specific health-related quality of life assessment tool for patients with pectus deformities. The aim of this study is to adapt the NQmA into Turkish. METHODS: Two hundred and sixty-five patients with PE were participated, with an age range of 14 to 29 years. All patients underwent a physical examination and had not undergone corrective surgery. The Turkish version of the NQmA was completed by patients and their parents. RESULTS: The content validity index based on expert opinions was 91% for the patient questionnaire and 96% for the parent questionnaire. The Cronbach's alpha value for the NQmA was found to be 0.805 for the patient questionnaire and 0.800 for the parent questionnaire. Exploratory factor analysis was used to assess construct validity. Two factors explained 51.1% of the total variance in the patient questionnaire (psychosocial: 31.145%, Cronbach's alpha=0.818; physical: 19.955%, Cronbach's alpha=0.862). In the parent questionnaire, two factors explained 51.422% of the total variance (psychosocial: 26.097%, Cronbach's alpha=0.743; physical: 25.325%, Cronbach's alpha=0.827). Construct validity was confirmed by confirmatory factor analysis. CONCLUSION: The Turkish version of the NQmA was found to be valid and reliable for the assessment of quality of life in patients with PE.

Quality of life improves after minimally invasive repair of pectus excavatum.

BACKGROUND: Pectus excavatum is the most common chest wall deformity. This deformity may cause physical limitations and psychosocial problems. In this study, we aimed to investigate the effect of minimally invasive repair of pectus excavatum on the quality of life. METHODS: This study included 88 patients, aged 18.44 ± 3.93 years (85.2% male), who underwent minimally invasive repair of pectus excavatum; 40.9% had an associated anomaly or disease, and 17.0% had scoliosis. The patients and their parents completed the patient and parent forms of the Nuss questionnaire modified for adults preoperatively and 6 months after the operation. RESULTS: The patients' median Nuss score increased from 31 (interquartile range 31-35) preoperatively to 43 (interquartile range 43-46) at 6 months after the operation (p = 0.000). The parents' preoperative score of 33 (interquartile range 29-36) increased to 38 (interquartile range 34-41; p = 0.000). Improvements in the physical and psychosocial component scores of the Nuss questionnaire were also significant in the patient (p = 0.000, p = 0.000, respectively) and parent forms (p = 0.005, p = 0.000, respectively). CONCLUSIONS: Minimally invasive repair of pectus excavatum significantly improved the physical and psychosocial wellbeing of patients. Longitudinal studies are needed to determine the long-term changes related to quality of life.

Reconstruction of sternal cleft with autologous cartilage graft in an adult.

Sternal cleft is a rare chest wall deformity associated with various malformations. Primary closure is the gold standard in the newborn period. Alternative techniques are possible for older patients. A 23-year-old woman with a partial sternal cleft and no additional deformity, underwent reconstruction using costal cartilage grafts. Postoperative physical and functional were excellent.

Preoperative chemoradiation therapy decreases the number of lymph nodes resected during esophagectomy.

BACKGROUND: This study aimed to analyze the effect of preoperative chemoradiation on the adequacy of lymph node dissection. METHODS: Patients with esophageal cancer treated with esophagectomy by the same surgeon between 2004 and 2011 were reviewed. Specimens were examined by the same pathologist. Patients were grouped into two depending on the type of treatment received. RESULTS: Forty-seven patients with curative esophagectomy were included in the study. Twenty patients had preoperative chemoradiation followed by surgery and 27 had surgery alone. Open and hybrid esophagectomy approaches were used. The average number of lymph nodes dissected was 16 ± 10 (1-39). There was a significant decrease in the number of lymph nodes examined in patients with preoperative chemoradiotherapy in comparison to surgery alone (p = 0.001). Median length of stay was 12 days. R0 resection rate was 96%. The median survival was 36.3 months, with a 42% 5-year survival. Seven patients (25%) had complete pathologic response following chemoradiation. No significant difference was recorded in terms of disease recurrence (p = 0.3). While morbidity was higher in the preoperative therapy group with 30 day mortality of 10%, type of surgical approach does not seem to influence the number of lymph nodes dissected (p = 0.7). CONCLUSIONS: Preoperative chemoradiation decreases the number of harvested lymph nodes following esophagectomy regardless of the surgical technique used. The optimum number of lymph nodes currently recommended to be dissected for accurate nodal staging and survival needs revision in this group of patients.

Refractory invasive aspergillosis controlled with posaconazole and pulmonary surgery in a patient with chronic granulomatous disease: case report.

Invasive aspergillosis is an important cause of morbidity and mortality in immunocompromised patients. Among primary immunodefiencies, chronic granulomatous disease (CGD) has the highest prevalence of invasive fungal diseases. Voriconazole is recommended for the primary treatment of invasive aspergillosis in most patients. In patients whose aspergillosis is refractory to voriconazole, therapeutic options include changing class of antifungal, for example using an amphotericin B formulation, an echinocandin, combination therapy, or further use of azoles. Posaconazole is a triazole derivative which is effective in Aspergillosis prophylaxis and treatment. Rarely, surgical therapy may be needed in some patients. Lesions those are contiguous with the great vessels or the pericardium, single cavitary lesion that cause hemoptysis, lesions invading the chest wall, aspergillosis that involves the skin and the bone are the indications for surgical therapy.Chronic granulomatous disease (CGD) is an inherited immundeficiency caused by defects in the phagocyte nicotinamide adenine dinucleotidephosphate (NADPH) oxidase complex which is mainstay of killing microorganisms. CGD is characterized by recurrent life-threatening bacterial and fungal infections and by abnormally exuberant inflammatory responses leading to granuloma formation, such as granulomatous enteritis, genitourinary obstruction, and wound dehiscence. The diagnosis is made by neutrophil function testing and the genotyping.Herein, we present a case with CGD who had invasive pulmonary aspergillosis refractory to voriconazole and liposomal amphotericine B combination therapy that was controlled with posaconazole treatment and pulmonary surgery.

Do Nuss bars compromise the blood flow of the internal mammary arteries?

OBJECTIVES: Minimally invasive repair of pectus excavatum, the so-called Nuss procedure, has become a popular technique in recent years. The internal mammary arteries (IMAs) lie on the posterolateral surface of the sternum, and the Nuss bar is likely to obstruct the blood flow in these arteries. This obstruction could become important in the later stages of the lives of these young people if they were to require coronary artery bypass grafting. The goal of this study is to investigate the extent of obstruction of the IMAs caused by Nuss bars. METHODS: Data were collected prospectively on all patients who underwent the Nuss procedure between October 2011 and May 2012. Patients with a history of pectus excavatum repair by open surgery and those who were younger than 16 years of age were excluded. Computed tomography-angiography (CTA) was performed for the detection of IMA blood flow preoperatively and on the 10th postoperative day. Blood flow in the IMAs was evaluated blindly by two radiologists and classified as blood flow unaffected (group I) or affected (group II) by comparing the assessment of preoperative and postoperative CTAs. The patients in group II were also categorized as having blood flow obstructed bilaterally, blood flow obstructed unilaterally and others (diminished unilaterally/diminished on one side or obstructed on the other side). RESULTS: Thirty-four patients (31 male and three female; mean age 20.7 ± 4.2 years) underwent surgery. Blood flow was affected in 15 patients (44%), with bilateral obstruction in five, unilateral obstruction in seven, and unilateral diminished flow in two patients. In one patient, blood flow was diminished on one side and obstructed on the other. There was no significant difference between unaffected group I patients and affected group II patients in terms of sex, age, type of deformity, Haller index and the number of bars placed. CONCLUSIONS: Nuss bars cause pressure on the IMAs, but a risk factor for this effect could not be identified. This is a relatively common clinical consequence of minimally invasive repair of pectus excavatum, and the long-term effects will be apparent following bar removal.

Pulmonary endarterectomy for chronic thrombo-embolic pulmonary hypertension: an institutional experience.

OBJECTIVE: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thrombo-embolic pulmonary hypertension (CTEPH). The aim of this study was to review our initial experience since the implementation of our program. METHODS: Data were collected prospectively on all patients who underwent PEA between March 2011 and March 2012. RESULTS: Forty-nine patients (20 male, 29 female, mean age 47.7 years) underwent surgery. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (n = 40). Mortality rate was 14.2% (n = 7) and the morbidity rate was 26.5% (n = 13). After PEA, the durations of mechanical ventilation, intensive care stay and hospital stay before discharge were 49.7 ± 46.1 h, 6.5 ± 5.0 days and 12.9 ± 7.5 days, respectively. The systolic and mean pulmonary artery pressure (PAP) fell significantly from 87.0 ± 26.6 mmHg and 53.8 ± 14.5 before, to 41.5 ± 12.4 mmHg and 28.5 ± 10.5 after surgery (P < 0.001 and P < 0.001, respectively). Pulmonary vascular resistance (PVR) also improved significantly from 808 ± 352.0 to 308 ± 91 dyn•s•cm(-5) (P < 0.001). Univariate analysis showed that preoperative systolic PAP, tricuspid annular plane systolic excursion, right atrial volume, right atrial pressure, forced expiratory volume in 1 s, forced vital capacity, preoperative PVR, postoperative PVR, the duration of circulatory arrest and postoperative use of extracorporeal membrane oxygenation were risk factors for mortality (P < 0.05). According to multivariate analyses, only prolonged mechanical ventilation was selected as predictive risk factor for morbidity (P = 0.005). After a median follow-up of 6.1 months, two patients died due to cerebrovascular disease and one patient needed targeted pulmonary hypertension therapy. The rest of the 39 patients showed marked improvements in their clinical status. CONCLUSIONS: Starting a pulmonary endarterectomy program with acceptable mortality and morbidity rates and satisfactory early-term outcomes increases awareness of the CTEPH and surgery. Preoperative factors can primarily predict postoperative outcome after PEA. Identifying the risk factors in order to achieve a good result is important for the success of a PEA program. Therefore all patients diagnosed with CTEPH should be referred for consideration of PEA in a specialized centre.