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CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
1. Andrea M D’Armini, MD, FCCP PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE “CTEPH” Cardiac Surgery University of Pavia School of Medicine Foundation I.R.C.C.S. “San Matteo” Hospital Pavia, Italy
9. U. G. PRE DLTx U. G. 1° POST DLTx DLTx for FAMILIAL PULMONARY HYPERTENSION PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE THORACIC TRANSPLANTATION 1357 TRANSPLANTS (17/11/1985 – 09/06/2011)
11. HLTx for EISENMENGER’S SYNDROME M. P. PRE HLTx M. P. 1° POST HLTx PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE THORACIC TRANSPLANTATION 1357 TRANSPLANTS (17/11/1985 – 09/06/2011)
12. HLTx for EISENMENGER’S SYNDROME PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE THORACIC TRANSPLANTATION 1357 TRANSPLANTS (17/11/1985 – 09/06/2011) Systolic Pulmonary Arterial Pressure 105 mmHg Right Ventricular End-Diastolic Diameter 110 mm Inferior Vena Cava 34 mm PRE-OPERATIVE ECHOCARDIOGRAPHY Right Atrium 6 mmHg Right Ventricle 23/0 mmHg Pulmonary Arterial Pressure 23/11/6 mmHg Pulmonary Capillary Wedge Pressure 6 mmHg Cardiac Output 7.1 L/min Cardiac Index 4.3 L/min/m 2 Pulmonary Vascular Resistance 45 dyne*sec*cm -5 POST-OPERATIVE RIGHT HEART CATHETERIZATION
28. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CLINIC The clinical indication changes substantially according to the different surgical treatment of CTEPH
35. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE S.S. – 31 yrs M – Sep 2002 Perfusion and ventilation scan Pulmonary angiogram Hemodynamic mPAP 50 CI 1.8 PVR 1120
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37. Concomitant severe parenchymal lung disease is the real absolute contraindication to PEA Such patients are not suitable for PEA and must be listed for DLTx (if indicated) PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONTRAINDICATION TO PEA
38. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE P.B. – 60 yrs M – Jun 2002 Perfusion and ventilation scintigraphy Pulmonary angiography CT scan Hemodynamic mPAP 28 CI 1.9 PVR 645
51. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MAIN WORLD PEA CENTERS Paris, France ≈ 100 PEAs / year NATIONAL REFERRAL PROGRAM FOR EXCELLENCE Cambridge, UK ≈ 80 PEAs / year NATIONAL REFERRAL PROGRAM BY LAW Pavia, Italy ≈ 60 PEAs / year MORE THAN ONE PROGRAM Bad Nauheim, Germany ≈ 50 PEAs / year MORE THAN ONE PROGRAM San Diego, California, USA ≈ 130 PEAs / year NATIONAL REFERRAL PROGRAM FOR EXCELLENCE
52. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL TREATMENT OF CTEPH 08-MAR-1991 First HLTx for CTEPH 11-APR-1994 First PEA 28-JUL-2003 First PEA in patient listed for DLTx 25-DEC-1995 First DLTx for CTEPH
74. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE I vs. TYPE II vs. TYPE III L.M.E.L. - 65 yrs M - Oct 2004 - PEA #119 mPAP 39 19 (-51%) CO 4.4 5.4 (+23%) PVR 665 222 (-66%) G.A.C. - 52 yrs F - Jul 2003 - PEA #96 mPAP 48 27 (-44%) CO 2.1 4.2 (+100%) PVR 1638 381 (-77%) B.A. - 43 yrs F - May 2009 - PEA #233 mPAP 49 19 (-61%) CO 3.3 5.0 (+52%) PVR 1067 224 (-79%)
75. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III B.A. - 43 yrs F - May 2009 - PEA #233 mPAP 49 19 (-61%) CO 3.3 5.0 (+52%) RVEF 16 35 (+119%) PVR 1067 224 (-79%)
76. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT F.C. - 33 yrs F - Apr 2009 - PEA #225 mPAP 52 20 (-62%) CO 4.6 4.7 (+2%) RVEF 32 41 (+28%) PVR 870 255 (-71%) PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III
77. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OUT OF PROPORTION PH ? Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT B.R.A. - 72 yrs F mPAP 44 CO 2.9 RVEF 28 PVR 1159
78. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT B.R.A. - 72 yrs F - Mar 2009 - PEA #222 mPAP 44 33 (-25%) CO 2.9 4.9 (+69%) RVEF 28 34 (+21%) PVR 1159 457 (-61%) B.R.A. - 72 yrs F mPAP 44 CO 2.9 RVEF 28 PVR 1159
79. Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT G.G. - 62 yrs F mPAP 51 CO 2.6 RVEF 19 PVR 1415 PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OUT OF PROPORTION PH ?
80. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE JAMIESON TYPE III Pre-operative Pulmonary Angiogram Pre-operative 64-HRCT G.G. - 62 yrs F - Sep 2009 - PEA #240 mPAP 51 27 (-47%) CO 2.6 4.0 (+54%) RVEF 19 24 (+26%) PVR 1415 460 (-68%) G.G. - 62 yrs F mPAP 51 CO 2.6 RVEF 19 PVR 1415
81. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CUMULATIVE PROPORTION SURVIVING OF 357 PEAs Operative mortality Global 32/357 (9.0%) NYHA II 0/33 (0.0%) NYHA III 8/165 (4.8%) NYHA IV 24/159 (15.1%) Jan 08 – May 11 13/183 (7.1%) 89.2 1.9 87.1 2.2 86.5 2.2 85.6 2.4 84.5 2.6 83.1 2.9 81.6 3.2 79.2 3.9 79.2 3.9
82. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CUMULATIVE PROPORTION SURVIVING SURGERY vs. MEDICAL THERAPY Riedel M. Chest 1982;81(2):151-8. D ’ Armini A.M. Ital Heart J 2005;6(10):861-8.
83. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CUMULATIVE PROPORTION SURVIVING 45 PTS ON WAITING LIST FOR TRANSPLANT IN CTEPH
84. SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CUMULATIVE PROPORTION SURVIVING 18 TRANSPLANTS IN CTEPH
85. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UP In literature few data are reported on mid- and long- term cardiopulmonary function, particularly on exertion, and on clinical outcomes after PEA