Does Age Matter? Pulmonary Endarterectomy in the Elderly Patient with CTEPH

Abstract

Background The gold standard treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) is pulmonary endarterectomy (PEA). Little is known about the influence of advanced age on surgical outcome. Therefore, the aim of this study was to investigate the impact of patient's age on postoperative morbidity, mortality, and quality of life in a German referral center.

Methods Prospectively collected data from 386 consecutive patients undergoing PEA between 01/2014 and 12/2016 were analyzed. Patients were divided into three groups according to their age: group 1: ≤ 50 years, group 2: > 50 ≤ 70 years, group 3: > 70 years.

Results After PEA, distinct improvements in pulmonary hemodynamics, physical capacity (World Health Organization [WHO] functional class and 6-minute walking distance) and quality of life were found in all groups. There were more complications in elderly patients with longer time of invasive ventilation, intensive care, and in-hospital stay. However, the in-hospital mortality was comparable (0% in group 1, 2.6% in group 2, and 2.1% in group 3 [p = 0.326]). Furthermore, the all-cause mortality at 1 year was 1.1% in group 1, 3.2% in group 2, and 6.3% in group 3 (p = 0.122).

Conclusions PEA is an effective treatment for CTEPH patients of all ages accompanied by low perioperative and 1-year mortality. CTEPH patients in advanced age carefully selected by thorough preoperative evaluation should be offered PEA in expert centers to improve quality of life, symptoms, and pulmonary hemodynamics.

Keywords

pulmonary vascular resistance/hypertension - pulmonary embolism - surgery - complications - outcomes (includes mortality morbidity)

Ethics Approval and Consent to Participate

All patients were informed in detail and gave written informed consent to participate. The local ethics committee approved this prospective observational study (AZ 218/13, Giessen University Ethics Committee) and is in accordance with the declaration of Helsinki.

Consent for Publication

All patients furthermore agreed with publication of scientific results of the obtained data.

Availability of Data and Material

All data has been stored pseudonymized in a password-secured database.

Authors' Contributions

CBW, DB, HAG, EM, and SG conceptualized and designed the work.

CBW, DB, KA, CL, SDK, and SG acquired and analyzed the data.

CBW, DB, HAG, SDK, CL, DP, SDK, and SG interpreted the data.

CBW, DB, ML, CL, SDK, and SG drafted the work and substantively revised it.

CBW, DB, KA, HAG, ML, CL, DP, EM, SDK, and SG approved the submitted version.

CBW, DB, KA, HAG, ML, CL, DP, EM, SDK, and SG agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.

^* Both authors contributed equally as last authors.

Publication History

Received: 14 July 2021

Accepted: 15 October 2021

Article published online:
17 January 2022

• References

• 1 Galiè N, Humbert M, Vachiery JL. et al; ESC Scientific Document Group. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur Heart J 2016; 37 (01) 67-119
• 2 Kim NH, Delcroix M, Jais X. et al. Chronic thromboembolic pulmonary hypertension. Eur Respir J 2019; 53 (01) 1801915
• 3 Pepke-Zaba J, Delcroix M, Lang I. et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an international prospective registry. Circulation 2011; 124 (18) 1973-1981
• 4 Mayer E. Surgical and post-operative treatment of chronic thromboembolic pulmonary hypertension. Eur Respir Rev 2010; 19 (115) 64-67
• 5 Thistlethwaite PA, Madani M, Jamieson SW. Outcomes of pulmonary endarterectomy surgery. Semin Thorac Cardiovasc Surg 2006; 18 (03) 257-264
• 6 Mayer E, Jenkins D, Lindner J. et al. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg 2011; 141 (03) 702-710
• 7 Jamieson SW, Kapelanski DP, Sakakibara N. et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann Thorac Surg 2003; 76 (05) 1457-1462 , discussion 1462–1464
• 8 Kim NH, Delcroix M, Jenkins DP. et al. Chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol 2013; 62 (25, Suppl): D92-D99
• 9 Ghofrani HA, D'Armini AM, Grimminger F. et al; CHEST-1 Study Group. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. N Engl J Med 2013; 369 (04) 319-329
• 10 Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv 2012; 5 (06) 748-755
• 11 Olsson KM, Wiedenroth CB, Kamp JC. et al. Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience. Eur Respir J 2017; 49 (06) 1602409
• 12 Thistlethwaite PA, Kaneko K, Madani MM, Jamieson SW. Technique and outcomes of pulmonary endarterectomy surgery. Ann Thorac Cardiovasc Surg 2008; 14 (05) 274-282
• 13 Madani MM, Auger WR, Pretorius V. et al. Pulmonary endarterectomy: recent changes in a single institution's experience of more than 2,700 patients. Ann Thorac Surg 2012; 94 (01) 97-103 , discussion 103
• 14 Lankeit M, Krieg V, Hobohm L. et al. Pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2017; •••: S1053-S2498
• 15 Berman M, Hardman G, Sharples L. et al. Pulmonary endarterectomy: outcomes in patients aged >70. Eur J Cardiothorac Surg 2012; 41 (06) e154-e160
• 16 Newnham M, Hernández-Sánchez J, Dunning J. et al. Age should not be a barrier for pulmonary endarterectomy in carefully selected patients. Eur Respir J 2017; 50 (06) 1701804
• 17 Grazioli V, Ghio S, Pin M. et al. Pulmonary endarterectomy in the octogenarian population: safety and outcomes. J Cardiovasc Med (Hagerstown) 2021; 22 (07) 567-571
• 18 Kriechbaum SD, Wiedenroth CB, Peters K. et al. Galectin-3, GDF-15, and sST2 for the assessment of disease severity and therapy response in patients suffering from inoperable chronic thromboembolic pulmonary hypertension. Biomarkers 2020; 25 (07) 578-586
• 19 Kriechbaum SD, Rudolph F, Wiedenroth CB. et al. Pregnancy-associated plasma protein A - a new indicator of pulmonary vascular remodeling in chronic thromboembolic pulmonary hypertension?. Respir Res 2020; 21 (01) 204
• 20 Krieg VJ, Hobohm L, Liebetrau C. et al. Risk factors for chronic thromboembolic pulmonary hypertension - importance of thyroid disease and function. Thromb Res 2020; 185: 20-26
• 21 Kriechbaum SD, Wiedenroth CB, Hesse ML. et al. Development of renal function during staged balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension. Scand J Clin Lab Invest 2019; 79 (04) 268-275
• 22 Kriechbaum SD, Wiedenroth CB, Keller T. et al. Dynamics of high-sensitivity cardiac troponin T during therapy with balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. PLoS One 2018; 13 (09) e0204683
• 23 Wiedenroth CB, Ghofrani HA, Adameit MSD. et al. Sequential treatment with riociguat and balloon pulmonary angioplasty for patients with inoperable chronic thromboembolic pulmonary hypertension. Pulm Circ 2018; 8 (03) 2045894018783996
• 24 Kriechbaum SD, Wiedenroth CB, Wolter JS. et al. N-terminal pro-B-type natriuretic peptide for monitoring after balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2018; 37 (05) 639-646
• 25 Wiedenroth CB, Liebetrau C, Breithecker A. et al. Combined pulmonary endarterectomy and balloon pulmonary angioplasty in patients with chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2016; 35 (05) 591-596
• 26 Roller FC, Kriechbaum S, Breithecker A. et al. Correlation of native T1 mapping with right ventricular function and pulmonary haemodynamics in patients with chronic thromboembolic pulmonary hypertension before and after balloon pulmonary angioplasty. Eur Radiol 2019; 29 (03) 1565-1573
• 27 Guth S, Wiedenroth CB, Wollenschläger M. et al. Short-term venoarterial extracorporeal membrane oxygenation for massive endobronchial hemorrhage after pulmonary endarterectomy. J Thorac Cardiovasc Surg 2018; 155 (02) 643-649
• 28 McCabe C, Bennett M, Doughty N, MacKenzie Ross R, Sharples L, Pepke-Zaba J. Patient-reported outcomes assessed by the CAMPHOR questionnaire predict clinical deterioration in idiopathic pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension. Chest 2013; 144 (02) 522-530
• 29 Daily PO, Dembitsky WP, Iversen S. Technique of pulmonary thromboendarterectomy for chronic pulmonary embolism. J Card Surg 1989; 4 (01) 10-24