Less Is More? Combined Approaches to Improve Mortality and Morbidity after Aortic Valve Replacement.

BACKGROUND: Nowadays, one of the main goals of aortic valve surgery is to reduce the biological impact, mortality, and complications. It is well-known that long operative times in terms of the extracorporeal circulation, but above all, of the aortic cross-clamp time (ACC), represent a risk factor for mortality in patients undergoing cardiac surgery. In order to shorten the aortic cross-clamp time, many technological improvements, such as sutureless prostheses, have been introduced, but their actual effectiveness has not been proven yet. The aim of this study was to assess the 30-day outcomes of patients undergoing aortic valve replacement surgery, focusing on the ACC length. METHODS: All 3139 patients undergoing aortic valve replacement between January 2013 and July 2022 at our institution were enrolled. The data were retrospectively collected and the baseline characteristics and intraoperative variables were recorded. In order to adjust the results according to the differences in the baseline characteristics, propensity score matching was performed and four groups of 351 patients were obtained based on the first, second, third, and fourth quartile of the ACC time. RESULTS: The patient population included 132 redo surgeries (9.4%) and 61 cases of active endocarditis (4.3%), with an overall median EuroSCORE II of 1.8 (IQR 1.2-3.1). An increase across the groups was observed in terms of the acute kidney failure (p < 0.001) incidence, the number of blood transfusions (p = 0.022), prolonged hospital stays (p < 0.001), the and respiratory failure (p < 0.001) incidence. A p of < 0.1 was found for the 30-day mortality (p = 0.079). The predictors of an early 30-day mortality were standard full sternotomy (OR 2.48, 95% CI 1.14-5.40, p = 0.022), EuroSCORE II (OR 1.10, 95% CI 1.05-1.16, p < 0.001), and a trend for a longer ACC time (Q4 vs. Q1: OR 2.62, 95% CI 0.89-7.68, p = 0.080). CONCLUSIONS: Shortening the operative times resulted in marked improvements of the patients' outcomes. The combined use of minimally invasive approaches and sutureless aortic valve prostheses allows for a lower 30-day events rate. New technologies should be assessed to obtain the best results with the least risk.

Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension: Relationship between treated branches and outcome.

BACKGROUND: In patients with chronic thromboembolic pulmonary hypertension (CTEPH) undergoing pulmonary endarterectomy (PEA) it is important to minimize residual obstructions, in order to achieve low postoperative pulmonary vascular resistances and better clinical results. The aim of the study was to test the hypothesis that the greater the number of pulmonary artery branches treated at surgery, the better the hemodynamic and clinical outcome after PEA. METHODS: In 564 consecutive CTEPH patients undergoing PEA the count of the number of treated branches was performed directly on the surgical specimens. Post-operative follow-up visits were scheduled at 3 months and 12 months after surgery including right heart catheterization and modified Bruce test. RESULTS: The population was divided into tertiles based on the number of treated branches: Group 1 (from 4 to 30 treated branches, n = 194 patients); Group 2 (from 31 to 43 treated branches, n = 190 patients); Group 3 (from 44 to 100 treated branches, n = 180 patients). At 3 and at 12 months after PEA, after adjustment for confounders, patients in the highest tertile of treated branches had significantly lower values of pulmonary vascular resistance and higher values of pulmonary arterial compliance as compared to the other two groups (p < 0.002). Hospital mortality was 3% in Group 3, 6% in Group 2 and 10% in Group 1 (overall p = 0.035). CONCLUSIONS: In CTEPH patients undergoing PEA, a higher number of treated pulmonary artery branches is associated with a better hemodynamic and a better clinical outcome at 3 months and 12 months after surgery.

Surgical aortic valve replacement for low-gradient aortic stenosis.

AIMS: Low-gradient aortic stenosis is a challenging entity that needs accurate preoperative evaluation. For this high-risk patient population, ad hoc predictive scores are not available and profile risk is currently revealed by the EuroSCOREs. Aims of this study are to verify the suitability of the ES II as predictor of mortality in low-gradient aortic stenosis and to analyse the role of surgery as a treatment. METHODS: From June 2013 to August 2019, 414 patients underwent surgical aortic valve replacement for low-gradient aortic stenosis. Mean age was 75.78 ±â€Š6.77 years and 190 were women. The prognostic value of Logistic EuroSCORE and EuroSCORE II were compared by receiver-operating characteristics (ROC) curve analysis. RESULTS: In-hospital, 30-day and 1-year mortality rates were respectively 3.4, 2.9 and 4.8% (14, 12 and 20 patients over 414). In-hospital mortality risk calculated by the Additive EuroSCORE was 7.2 ±â€Š2.7%, by the Logistic EuroSCORE was 9 ±â€Š5.2% and by the ES II was 4.13 ±â€Š2.56%. The prognostic values of the EuroSCORE II and of the EuroSCORE were analysed in a ROC curve analysis for the prediction of in-hospital mortality [area under the curve (AUC): 0.62 vs. 0.58], 30-day mortality (AUC: 0.63 vs. 0.64) and 1-year mortality (AUC: 0.79 vs. 0.65). Both scores did not show significant differences with the only exception of 1-year mortality, for which EuroSCORE II had a better predictive ability than the Logistic EuroSCORE (P < 0.05). CONCLUSION: In low-gradient aortic stenosis undergoing surgery, the EuroSCORE II is a strong predictor of 1-year mortality.

Impact of comorbidities on older patients undergoing open heart surgery.

BACKGROUND: The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery. METHODS: Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019. RESULTS: In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death. CONCLUSION: Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Biological Characterization of Human Autologous Pericardium Treated with the Ozaki Procedure for Aortic Valve Reconstruction.

BACKGROUND: The Ozaki procedure is an innovative surgical technique aiming at reconstructing aortic valves with human autologous pericardium. Even if this procedure is widely used, a comprehensive biological characterization of the glutaraldehyde (GA)-fixed pericardial tissue is still missing. METHODS: Morphological analysis was performed to assess the general organization of pericardium subjected to the Ozaki procedure (post-Ozaki) in comparison to native tissue (pre-Ozaki). The effect of GA treatment on cell viability and nuclear morphology was then investigated in whole biopsies and a cytotoxicity assay was executed to assess the biocompatibility of pericardium. Finally, human umbilical vein endothelial cells were seeded on post-Ozaki samples to evaluate the influence of GA in modulating the endothelialization ability in vitro and the production of pro-inflammatory mediators. RESULTS: The Ozaki procedure alters the arrangement of collagen and elastic fibers in the extracellular matrix and results in a significant reduction in cell viability compared to native tissue. GA treatment, however, is not cytotoxic to murine fibroblasts as compared to a commercially available bovine pericardium membrane. In addition, in in vitro experiments of endothelial cell adhesion, no difference in the inflammatory mediators with respect to the commercial patch was found. CONCLUSIONS: The Ozaki procedure, despite alteration of ECM organization and cell devitalization, allows for the establishment of a noncytotoxic environment in which endothelial cell repopulation occurs.

Radiological differences between chronic thromboembolic pulmonary disease (CTEPD) and chronic thromboembolic pulmonary hypertension (CTEPH).

OBJECTIVES: The aim of this study was to describe the radiological features of chronic thromboembolic pulmonary disease (CTEPD), not yet systematically described in the literature. Furthermore, we compared vascular scores between CTEPD and chronic thromboembolic pulmonary hypertension (CTEPH) patients, trying to explain why pulmonary hypertension does not develop at rest in CTEPD patients. METHODS: Eighty-five patients (40 CTEPD, 45 CTEPH) referred to our centre for pulmonary endarterectomy underwent dual-energy computed tomography pulmonary angiography (DE-CTPA) with iodine perfusion maps; other 6 CTEPD patients underwent single-source CTPA. CT scans were reviewed independently by an experienced cardiothoracic radiologist and a radiology resident to evaluate scores of vascular obstruction, hypoperfusion and mosaic attenuation, signs of pulmonary hypertension and other CT features typical of CTEPH. RESULTS: Vascular obstruction burden was similar in the two groups (p = 0.073), but CTEPD patients have a smaller extension of perfusion defects in the iodine map (p = 0.009) and a smaller number of these patients had mosaic attenuation (p < 0.001) than CTEPH patients, suggesting the absence of microvascular disease. Furthermore, as expected, the two groups were significantly different considering the indirect signs of pulmonary hypertension (p < 0.001). CONCLUSIONS: CTEPD and CTEPH patients have significantly different radiological characteristics, in terms of signs of pulmonary hypertension, mosaic attenuation and iodine map perfusion extension. Importantly, our results suggest that the absence of peripheral microvascular disease, even in presence of an important thrombotic burden, might be the reason for the absence of pulmonary hypertension in CTEPD. KEY POINTS: • CTEPD and CTEPH patients have significantly different radiological characteristics. • The absence of peripheral microvascular disease might be the reason for the absence of pulmonary hypertension in CTEPD.

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

BACKGROUND: Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population. METHODS: From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected. RESULTS: Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality. CONCLUSIONS: Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.

Pacemaker need after sutureless aortic valve replacement: the role of the learning curve.

AIM: Aortic valve replacement (AVR) using sutureless prosthesis is a reasonable alternative in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. Actually, excellent performances have been demonstrated in hemodynamic outcomes and safety, but some questions remain open regarding long-term durability and the need for postoperative pacemaker implantation. METHODS: Between January 2014 and August 2019, all 436 patients [male 40.6%, median age 78 years interquartile range (73-82)] treated with sutureless AVR with a Perceval prosthesis were included in our analysis. RESULTS: The univariate logistic regression showed previous aortic valve surgery [P = 0.028; odds ratio (OR) 3.248], dialysis (P = 0.036; OR 6.435), renal insufficiency (P = 0.021; OR 2.75), EuroSCORE II (P = 0.016; OR 1.051) and year of operation (P < 0.01; OR 0.658) as factors associated with the development of atrioventricular type II or type III block or junctional block requiring pacemaker implantation. The overall incidence of pacemaker implantation after sutureless AVR was 7.1% in the current study, but it dropped to 3.8 and 4.7%, respectively, in 2018 and 2019. CONCLUSION: The Perceval aortic valve is associated with encouraging postoperative results. The incidence of pacemaker implantation is strictly linked to the surgeons' experience, decreasing year by year after an adequate sizing, reaching a percentage comparable with sutured valve.

Pulmonary endarterectomy in the octogenarian population: safety and outcomes.

AIMS: Aim of the study was to verify the feasibility, safety and efficacy of pulmonary endarterectomy (PEA) in octogenarian patients with chronic thromboembolic pulmonary hypertension. METHODS: We retrospectively analyzed 635 chronic thromboembolic pulmonary hypertension patients who underwent PEA at our center and were followed-up for at least 1 year. The end-points of the study were in-hospital mortality, hemodynamic results at 1 year and long-term survival. RESULTS: In-hospital mortality was 4, 10 and 17%, respectively, for 259 patients under the age of 60 years, 352 aged between 60 and 79 years and 24 octogenarians (P = 0.006 octogenarians vs. <60 years). At multivariable analysis, age and pulmonary vascular resistances were independent risk factors for mortality (P = 0.021 and P < 0.001, respectively). At 1 year, the improvement in cardiac index was lower and the distance walked in 6 min was poorer for octogenarians than for the other two groups (both P = 0.001). Survival after hospital discharge was similar over a median follow-up period of 59 months (P = 0.113). Although in-hospital mortality and long-term survival are similar in octogenarians as compared with patients aged between 60 and 79, the improvement in cardiac index and in functional capacity at 1 year are lower in this very elderly population. CONCLUSION: Age over 80 years should not be a contraindication to PEA surgery in selected patients operated on in referral centers.

Interrupted aortic arch: A case report.

Interrupted aortic arch diagnosed in adult age is a rare entity, with only a few cases published in the literature. Most of them are classified as type A interrupted aortic arch and differential diagnosis is associated with severe chronic coarctation. We present a case of a 52-year-old woman accessed to the emergency department for chest and right upper limb pain that increased in the last days. She underwent a computed tomography angiogram showing interruption of the aortic arch, distal to left subclavian artery origin, large bilateral collateral vessels connecting subclavian arteries to descending aorta with multiple voluminous aneurysms, a bicuspid aortic valve, dilatated tubular segment of ascending thoracic aorta, and a suspected atrial septal defect. A nonsystematic literature review regarding these conditions has been performed.

Persistent exercise limitation after successful pulmonary endoarterectomy: frequency and determinants.

BACKGROUND: After successful pulmonary endoarterectomy (PEA), patients may still suffer from exercise limitation, despite normal pulmonary vascular resistance. We sought to assess the proportion of these patients after the extension of PEA to frail patients, and the determinants of exercise limitation. METHODS: Out of 553 patients treated with PEA from 2008 to 2016 at our institution, a cohort of 261 patients was followed up at 12 months. They underwent clinical, haemodynamic, echocardiographic, respiratory function tests and treadmill exercise testing. A reduced exercise capacity was defined as Bruce test distance < 400 m. RESULTS: Eighty patients did not had exercise testing because of inability to walk on treadmill and/or ECG abnormalities Exercise limitation 12 months after PEA was present in 74/181 patients (41, 95%CI 34 to 48%). The presence of COPD was more than double in patients with exercise limitation than in the others. Patients with persistent exercise limitation had significantly higher mPAP, PVR, HR and significantly lower RVEF, PCa, CI, VC, TLC, FEV1, FEV1/VC, DLCO, HbSaO2 than patients without. The multivariable model shows that PCa at rest and TAPSE are important predictors of exercise capacity. Age, COPD, respiratory function parameters and unilateral surgery were also retained. CONCLUSIONS: After successful PEA, most of the patients recovered good exercise tolerance. However, about 40% continues to suffer from limitation to a moderate intensity exercise. Besides parameters of right ventricular function, useful information are provided by respiratory function parameters and COPD diagnosis. This could be useful to better address the appropriate therapeutic approach.

Exercise Training After Pulmonary Endarterectomy for Patients with Chronic Thromboembolic Pulmonary Hypertension.

BACKGROUND: After undergoing a procedure of pulmonary endarterectomy (PEA), patients with chronic thromboembolic pulmonary hypertension (CTEPH) may still experience reduced exercise capacity. Data on effects of exercise training in these patients are scant. OBJECTIVES: To evaluate the effectiveness of exercise training after PEA for CTEPH and if the presence of "residual pulmonary hypertension" may affect the outcome. METHODS: Retrospective data analysis of CTEPH patients undergoing inpatient exercise training after PEA. According to predefined criteria, patients were divided into those with (group 1) and without (group 2) a "good" post-surgery hemodynamic response. Assessments of the 6-min walking distance test (6-min walking distance test [6 MWT]: primary outcome) were performed before and after surgery (before training), after training and at 3-month follow-up. Hemodynamic and lung function data were also analyzed. RESULTS: Data of 84 and 26 patients of groups 1 and 2, respectively, were analyzed. After surgery patients showed a reduction in 6 MWT, which significantly reversed after training and further improved at 3 months (p = 0.0001), without any significant difference between groups. The percentage of patients reaching the minimal clinically important difference in 6 MWT was similar between groups. The sig-nificant (p = 0.0001) post-surgery improvement in hemodynamics was maintained at 3 months without any significant difference between groups. New York Heart Association functional class improved in parallel to the hemodynamic improvement. CONCLUSIONS: Exercise training in patients with CTEPH after PEA, an inpatient exercise training program, improves exercise capacity for up to 3 months, independently of the post-surgery hemodynamic response.

High preoperative plasma endothelin-1 levels are associated with increased acute kidney injury risk after pulmonary endarterectomy.

OBJECTIVES: The only curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). PEA requires cardiopulmonary bypass (CPB) which is associated with a high acute kidney injury (AKI) risk. Circulating endothelin-1 (ET-1) levels are elevated in CTEPH, and ET-1 plays a pivotal role in AKI. Because AKI is burdened by high morbidity and mortality, we aimed to evaluate the association between preoperative ET-1 and the risk to develop AKI in CTEPH individuals who undergo PEA. We also evaluated the association of AKI and ET-1 with kidney function and mortality at 1 year after PEA. METHODS: In 385 consecutive patients diagnosed with CTEPH who underwent PEA at the Foundation IRCC Policlinico San Matteo (Pavia, Italy) from January 2009 to April 2015, we assessed preoperative circulating ET-1 by ELISA and identified presence of AKI based on 2012 KDIGO criteria. RESULTS: AKI occurred in 26.5% of the 347 patients included in the analysis, and was independently associated with preoperative ET-1 (p = 0.008), body mass index (BMI) (p = 0.022), male gender (p = 0.005) and duration of CPB (p = 0.002). At 1-year post PEA, estimated glomerular filtration rate (eGFR) significantly improved in patients who did not develop AKI [ΔeGFR 5.6 ml/min/1.73 m2 (95% CI 3.6-7.6), p < 0.001] but not in those with perioperative AKI. AKI (p < 0.001), age (p < 0.001), preoperative eGFR (p < 0.001) and systemic hypertension diagnosis (p = 0.015) were independently associated with 1-year ΔeGFR. Neither perioperative AKI nor preoperative ET-1 was associated with 1-year survival. CONCLUSION: Perioperative AKI is associated with higher preoperative circulating ET-1 and it negatively influences long-term kidney function in patients with CTEPH who undergo PEA.

Chronic thromboembolic pulmonary hypertension: Reversal of pulmonary hypertension but not sleep disordered breathing following pulmonary endarterectomy.

BACKGROUND: It has been hypothesized that pre-capillary pulmonary hypertension (PH) may trigger sleep disordered breathing (SDB). In patients with chronic thromboembolic PH (CTEPH), pulmonary endarterectomy (PEA) is potentially effective to improve PH. We assessed the pre- and post-operative prevalence of SDB in CTEPH patients submitted to PEA and the relationship between SDB and clinical, pulmonary and hemodynamic factors. METHODS: Unattended cardiorespiratory recording was performed the night before and one month after elective PEA in 50 patients. RESULTS: Before the intervention SDB prevalence (obstructive or central AHI ≥ 5/h) was 64%: 18 patients (66% female) had No-SDB, 22 (68% female) had dominant obstructive (dOSA), and 10 (20% female) had dominant central sleep apnea (dCSA). There were no differences in risk factors and the need for supplemental oxygen. Mean right atrial (mRAP) and pulmonary artery pressures (mPAP) showed a more compromised profile from No-SDB to dOSA and dCSA (mRAP: 5.5 ±â€¯3.9 vs 7.0 ±â€¯4.5 vs 9.7 ±â€¯4.3 mm Hg (p = 0.054), mPAP: 39 ±â€¯12 vs 48 ±â€¯11 vs 51 ±â€¯16 mm Hg (p = 0.0.47)). By contrast, cardiac index did not differ. At post-intervention, the prevalence of SDB was 68%: 16 patients had No-SDB, while 30 had dOSA and 4 dCSA, with no relationship with the relief from PH. Interestingly, 5 patients with previous CSA moved to the OSA group and 2 normalized. CONCLUSIONS: Prevalence of SDB is high in patients with CTEPH even after resolution of PH. Our data support the hypothesis that pre-capillary PH may trigger CSA but not OSA, and suggest that OSA may play a role in the development of CTEPH.

Neuropsychological outcomes after pulmonary endarterectomy using moderate hypothermia and periodic circulatory arrest.

BACKGROUND: In this prospective, single-center, observational study, we investigated the association between repeated short periods of circulatory arrest with moderate hypothermia during pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) and different neuropsychological dimensions. METHODS: We examined 70 patients with CTEPH, >18 to 80 years of age, who had been treated with PEA. Neuropsychological testing was performed. RESULTS: Learning ability and delayed memory remained well within the normal range for patients' age. We found a statistically significant post-surgical improvement in motor speed, which was accompanied by a better quality of life and reduced symptoms of depression and anxiety. CONCLUSION: PEA with repeated short periods of circulatory arrest in CTEPH did not result in any neuropsychological complications and may even lead to post-surgical psychological improvements.

Pavia Experience in Reoperative Pulmonary Endarterectomy.

In our experience, we reperformed pulmonary endarterectomy (PEA) in 10 patients who previously underwent a first PEA. We analyzed this cohort of patients to investigate the main causes of recurrence of symptomatic pathology and the clinical and hemodynamic results of redo surgery. Between 1994 and April 2016, 10 of 716 patients were reoperated at our institution. Available postoperative data were analyzed, and a comparison between first and second PEA hemodynamic and clinical results was carried out. In-hospital mortality rate was also evaluated. After reoperation, mean pulmonary arterial pressure decreased from 45?±?9 to 34?±?10?mm Hg, and pulmonary vascular resistance reduced from 932?±?346?dyne*s*cm?5 to 428?±?207?dyne*s*cm?5. Hemodynamic data revealed worthy results of redo PEA, although they are less important than after first PEA. The World Health Organization (WHO) functional class improvement demonstrated satisfactory clinical results. In-hospital mortality of repeat PEA is 40%. Reoperative PEA operative candidacy should be assessed in case of young patients, no other risk factor, and recent medical history of pulmonary hypertension. In the other cases, in-hospital mortality rate is very high and pulmonary hypertension-specific drug therapy or interventional approach should be previously considered.

Pulmonary endarterectomy in the elderly: safety, efficacy and risk factors.

AIMS: Pulmonary endarterectomy (PEA) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension, but there are few data in the literature about the results of this procedure in the elderly. In this study, we aimed to assess whether this type of surgery is effective and well tolerated for the elderly. METHODS: A total of 264 consecutive patients who underwent PEA between January 2008 and December 2012 were reviewed. PEA was performed under cardiopulmonary bypass and hypothermic ventricular fibrillation, with the aorta left unclamped. The population was dichotomized according to age into the following two groups: below 70 years (n = 176, younger patients) and at least 70-year-olds (n = 88, elderly patients). Regression models were used to identify predictors of hospital mortality and postoperative adverse events, and their interaction with age was tested. RESULTS: Hospital mortality was slightly, but not significantly higher in elderly patients (9.1 vs. 5.1%; P = 0.22). Effect modification by history of smoking and preoperative O2 therapy was present. The cumulative survival at 1, 2, and 4 years was 93, 92, and 91% among younger patients; and 88, 86, and 86% among older patients (P = 0.19). Clinical and hemodynamic improvement was similar in the two groups. CONCLUSION: Despite a slightly higher short-term mortality, PEA is feasible and well tolerated for the vast majority of the elderly patients. Clinical and hemodynamic improvements are outstanding, with satisfactory long-term survival rates.

Pulmonary endarterectomy for distal chronic thromboembolic pulmonary hypertension.

OBJECTIVES: 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.