Your SlideShare is downloading. ×
0
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

CTEPH, Surgcal and Medical Therapy. Terapia Chirurgica e medica

1,136

Published on

cteph, terapia chirurgica e medica

cteph, terapia chirurgica e medica

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
1,136
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
46
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide

Transcript

  • 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
  • 2. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BACKGROUND Chronic Thromboembolic Pulmonary Hypertension CTEPH Acute Pulmonary Embolism
  • 3. <ul><li>Chronic thromboembolic pulmonary hypertension (CTEPH) represents a sequel of non-resolved venous thromboembolism with fatal natural history due to chronic right ventricular failure </li></ul><ul><li>Progress in surgical treatment over the past decade has considerably improved the outcome of CTEPH patients </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BACKGROUND
  • 4. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INTRODUCTION <ul><li>CTEPH represents the only type of pulmonary hypertension surgically treatable, in the majority of cases, without transplant </li></ul><ul><li>This life-saving conservative surgery is called pulmonary endarterectomy (PEA) </li></ul>
  • 5. <ul><li>Vascular lung diseases suitable for transplantation are: </li></ul><ul><ul><li>Idiopathic Pulmonary Hypertension </li></ul></ul><ul><ul><li>Eisenmenger’s Syndrome </li></ul></ul><ul><ul><li>CTEPH </li></ul></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE VASCULAR LUNG DISEASES
  • 6. <ul><li>Eisenmenger’s Syndrome </li></ul><ul><ul><li>Idiophatic Pulmonary Hypertension </li></ul></ul>1990 2011 Optimal Medical Therapy BEFORE HL/L Transplantation PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE VASCULAR LUNG DISEASES
  • 7. <ul><li>10089 HEART TRANSPLANTS </li></ul><ul><li>309 LUNG TRANSPLANTS </li></ul><ul><li>39 HEART-LUNG TRANSPLANTS </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE THORACIC TRANSPLANTATION 1357 TRANSPLANTS (17/11/1985 – 09/06/2011) 1357 INTRATHORACIC TRANSPLANTS
  • 8. 348 LUNG AND HEART-LUNG TRANSPLANTS <ul><li>79 VASCULAR LUNG DISEASES </li></ul><ul><li>269 PARENCHYMAL LUNG DISEASES </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE THORACIC TRANSPLANTATION 1357 TRANSPLANTS (17/11/1985 – 09/06/2011)
  • 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)
  • 10. DLTx for FAMILIAL PULMONARY HYPERTENSION RIGHT HEART CATHETERIZATION PRE-DLTx 1° POST-DLTx Right Atrium 13 9 Right Ventricle 118/0 25/0 Pulmonary Arterial Pressure 118/82/60 38/25/16 ( -70% ) Systemic Arterial Pressure 96/76/61 113/73/53 Pulmonary Capillary Wedge Pressure 5 10 Cardiac Output 2.9 6.2 ( +114% ) Cardiac index 1.6 4.0 Pulmonary Vascular Resistance 2134 155 ( -91% ) 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
  • 13. 1990 2011 PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL TREATMENT OF CTEPH PAVIA EXPERIENCE - 357 PEAs <ul><li>CTEPH </li></ul><ul><li>( NO SPECIFIC DRUGS ARE CURRENTLY APPROVED FOR CTEPH ) </li></ul>From Transplant to Conservative Surgery (PEA)
  • 14. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INTRODUCTION <ul><li>Elective surgery, non donor-dependent </li></ul><ul><li>No “transplant window” to be considered </li></ul><ul><li>Age is not a contraindication </li></ul><ul><li>Lower post-operative complications </li></ul><ul><ul><li>early (acute graft failure, acute rejection, infections) </li></ul></ul><ul><ul><li>late (BOS, neoplasms, infections) </li></ul></ul><ul><li>Outcome </li></ul><ul><ul><li>post-operative long term survival </li></ul></ul><ul><ul><li>quality of life (back to normal) </li></ul></ul><ul><ul><li>steady functional improvement </li></ul></ul>PEA vs. LTx
  • 15. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE EPIDEMIOLOGY <ul><li>Epidemiologic data: in Italy ≈ 65.000 cases / year of acute symptomatic pulmonary embolism (PE) </li></ul><ul><li>Prevalence of CTEPH in pts surviving an acute PE ( ≈ 80 %) is calculated between 0.5% – 3.8% </li></ul><ul><li>-> up to 2.000 new cases / year </li></ul><ul><li>Considering asymptomatic pulmonary embolism and misdiagnosed pulmonary embolism, the true incidence of CTEPH may be even greater </li></ul><ul><li>Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg 2000; 37:165-252 </li></ul><ul><li>Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001; 345:1465-72 </li></ul><ul><li>Pengo V, Lensing AV, Prins MH, Marchiori A, Davidson BL, Tiozzo F et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med 2004; 350:2257-64 </li></ul>
  • 16. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CURRENT SITUATION <ul><li>CTEPH is still under-diagnosed and nowadays only few physicians are aware of the surgical procedure called PEA </li></ul><ul><li>For all these reasons about 8000 PEA have been performed worldwide so far with ≈ 30 % of all cases carried out by the San Diego Group </li></ul>
  • 17. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE NATURAL HISTORY <ul><li>Pulmonary embolism (symptomatic / asymptomatic) </li></ul><ul><li>“ Honeymoon ” period: months / years </li></ul><ul><li>Hypertensive remodeling of the patent pulmonary vascular bed (Eisenmenger-like) </li></ul><ul><li>Right ventricle hypertrophy with progressive right heart deterioration  right failure </li></ul><ul><li>Left ventricle compression with left heart functional impairment </li></ul>
  • 18. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE GENERAL CONDITIONS <ul><li>Low cardiac output with dyspnea, cough, cyanosis, hepatomegaly, ascites, lower limb edema, syncope, hemoptysis and interscapular olosystolic murmur </li></ul><ul><li>Hypoxemia with exercise, sometimes at rest also </li></ul><ul><li>Frequent positive anamnesis for deep venous thrombosis and / or coagulative and immunologic disorders </li></ul>
  • 19. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE COAGULATIVE DISORDERS DISORDER % PTS MEAN ± SD RANGE HYPERHOMOCYSTEINEMIA ( μ mol/L) 72.6 % 21.7 ± 8.3 14.1 – 63.2 EXCESS FACTOR VIII ANTIGEN (%) 78.2 % 206.7 ± 33.9 161.1 – 392.9 EXCESS FACTOR VIII RISTOCETIN (%) 47.6 % 182.1 ± 46.6 150.0 – 334.0 EXCESS FACTOR VIII (%) 27.4 % 179.3 ± 25.8 153.4 – 220.0 PAI EXCESS (U/ml) 53.2 % 5.1 ± 1.2 3.6 – 7.9 FACTOR V LEIDEN 15.3 % 1.34 ± 0.55 0.50 – 1.99
  • 20. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE IMMUNOLOGIC DISORDERS DISORDER % PTS MEAN ± SD RANGE Anti-Nuclear Antibodies (ANA) 23.4 % – – Lupus Anticoagulant (LAC) 19.4 % – – Anti-Cardiolipin Antibodies (ACA) IgG 20.2 % 56.3 ± 40.3 10.3 – 121.0 Anti-Cardiolipin Antibodies (ACA) IgM 13.7 % 30.8 ± 30.5 7.3 – 101.0 Anti-Phospholipid Antibodies (APA) IgG 14.5 % 63.2 ± 36.5 8.4 – 121.0 Anti-Phospholipid Antibodies (APA) IgM 12.9 % 28.0 ± 23.5 10.1 – 91.3 Positive Direct Coombs’ Test 8.9 % – –
  • 21. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE GENETIC MUTATIONS MUTATION % PTS C677T MTHFR (HOMOCYSTEINEMIA) HETEROZYGOSIS 50.8 % HOMOZYGOSIS 19.4 % TOTAL 70.2 % A1298C MTHFR (HOMOCYSTEINEMIA) HETEROZYGOSIS 44.4 % HOMOZYGOSIS 9.7 % TOTAL 54.1 % G20210A PROTHROMBIN (FACTOR II) 8.1 % G1691A FACTOR V (FACTOR V LEIDEN) 5.6 %
  • 22. <ul><li>A PERMANENT INFERIOR VENA CAVA FILTER was placed before PEA in the majority (335/357) of patients </li></ul><ul><li>Lifelong oral anticoagulation was prescribed after PEA </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MARKED THROMBOPHILIA
  • 23. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCE
  • 24. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCE
  • 25. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCE
  • 26. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCE
  • 27. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INDICATIONS FOR SURGERY <ul><li>The indications for the surgical treatment of these patients are based on </li></ul><ul><li>CLINIC </li></ul><ul><li>HEMODYNAMIC </li></ul><ul><li>The indications for the type of surgery are based on </li></ul><ul><li>ANATOMY </li></ul>
  • 28. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CLINIC The clinical indication changes substantially according to the different surgical treatment of CTEPH
  • 29. <ul><li>Age < 60 yrs </li></ul><ul><li>WHO III or IV </li></ul><ul><li>Contraindications </li></ul><ul><li>Tx “window” </li></ul><ul><li>Age is not a contraindication </li></ul><ul><li>Symptomatic PH (WHO II-III-IV ) </li></ul><ul><li>Absence of severe pulmonary parenchymal disease </li></ul><ul><li>Elective surgery </li></ul>Tx PEA PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CLINIC TRANSPLANT WINDOW TOO LATE TOO EARLY
  • 30. <ul><li>Pulmonary hypertension (mPAP  25 mmHg) </li></ul><ul><li>Pulmonary wedge pressure < 15 mmHg </li></ul><ul><li>Causing low cardiac output </li></ul><ul><li>Resulting in calculated pulmonary vascular resistances (PVR) > 300 dyne*sec*cm -5 </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE HEMODYNAMIC PRECAPILLARY PULMONARY HYPERTENSION
  • 31. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ANATOMY <ul><li>The surgical treatment depends on the localization of the lesions in the pulmonary arterial branches </li></ul><ul><li>Lesions can be classified as PROXIMAL </li></ul><ul><li>DISTAL </li></ul>
  • 32. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PROXIMAL LESIONS
  • 33. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE M.B. – 62 yrs M – Jul 2001 – PEA #64 Perfusion and ventilation scan Pulmonary angiogram Hemodynamic mPAP 67 CI 1.6 PVR 1766
  • 34. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE DISTAL LESIONS
  • 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
  • 36. <ul><li>Growing single surgeon’s experience due to learning curve </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OPERABILITY ASSESSMENT Which lesions have to be considered as inoperable ? <ul><li>Different operability assessments from different Centers </li></ul>
  • 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
  • 39. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BACKGROUND <ul><li>PEA is the treatment of choice for patients with CTEPH </li></ul><ul><li>About only 10-15 Centers worldwide are performing PEA on a routine basis </li></ul><ul><li>In expert hands, mortality ranges between 5% and 12% and technical failure is below 8% </li></ul><ul><li>Early hemodynamic results </li></ul><ul><li>are known to be excellent in </li></ul><ul><li>case of successful operation </li></ul>
  • 40. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCE
  • 41. <ul><li>National referral program </li></ul><ul><li>Begin: April 1994 </li></ul><ul><li>To date: 357 PEAs performed </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OUR PROGRAM
  • 42. 55 101 12 4 15 19 16 28 7 4 7 21 5 18 15 3 6 14 <ul><li>Pts coming from outside Italy </li></ul><ul><li>Greece 1 </li></ul><ul><li>Kosovo 1 </li></ul><ul><li>- Uganda 1 </li></ul>2 2 Pavia PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PATIENTS’ REFERRAL OF 357 PEAs ≤ 10 pts 11 – 20 pts ≥ 21 pts
  • 43. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS 65 PEAs in almost 8 yrs 65 PEAs in 1 yr
  • 44. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS NEW EVALUATIONS + 100%
  • 45. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS DIAGNOSTIC ACCURACY 63% 76% + 13%
  • 46. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS OPERABILITY RATE 74% 89% + 15%
  • 47. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS PEAs PERFORMED + 195 %
  • 48. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PAVIA CTEPH PROGRAM January, 1 st - December, 31 st 2004  130 pts EVALUATION (54 pts) FOLLOW-UP (72 pts) DLTx (4 pts) CONFIRMED (34 pts - 63%) OTHER DIAGNOSIS (20 pts - 37%) <ul><li>RECENT EMBOLIZATION (3 pts) </li></ul><ul><li>- 2 medical therapy </li></ul><ul><li>- 1 surgical embolectomy </li></ul><ul><li>TUMORS (5 pts) </li></ul><ul><li>- 3 pulmonary angiosarcoma </li></ul><ul><li>- 1 adenocarcinoma with pulmonary artery thrombosis </li></ul><ul><li>- 1 intestinal tumor with liver metastases </li></ul><ul><li>MISCELLANEOUS (12 pts) </li></ul>OPERABILITY RATE 74 % <ul><li>PROXIMAL LESIONS (25 pts) </li></ul><ul><li>- 22 PEAs </li></ul><ul><li>- 2 pts refused </li></ul><ul><li>- 1 pt died on evaluation </li></ul><ul><li>DISTAL LESIONS (7 pts) </li></ul><ul><li>- 5 DLTx waiting-list </li></ul><ul><li>- 2 medical therapy (too old for DLTx) </li></ul><ul><li>ASSOCIATION WITH SEVERE EMPHYSEMA (2 pts) </li></ul><ul><li>- 2 DLTx waiting-list </li></ul>
  • 49. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PAVIA CTEPH PROGRAM January, 1 st – December, 31 st 2010  231 pts New Evaluations (108 pts) PEAs FUP (99 pts) Clinical Trials (23 pts) HLTx (1 pt) CONFIRMED (82 pts - 76%) OTHER DIAGNOSIS (26 pts - 24%) OPERABILITY RATE 89 % <ul><li>PROXIMAL LESIONS (73 pts) </li></ul><ul><li>- 65 PEAs </li></ul><ul><li>- 4 pts waiting for PEA </li></ul><ul><li>- 3 pts refused PEA </li></ul><ul><li>- 1 pt with severe co-morbidities </li></ul><ul><li>DISTAL LESIONS (8 pts) </li></ul><ul><li>- 8 medical therapy: 5 too old for DLTx </li></ul><ul><li>3 too early for DLTx </li></ul><ul><li>RECENT EMBOLIZATION (6 pts) </li></ul><ul><li>- 3 medical therapy </li></ul><ul><li>- 3 surgical embolectomy </li></ul><ul><li>MINIMAL CTE LESIONS WITHOUT PH (2 pts) </li></ul><ul><li>- 2 medical therapy </li></ul><ul><li>MISCELLANEOUS (15 pts) </li></ul><ul><li>TUMOR (3 pts) </li></ul><ul><li>- 3 pulmonary angiosarcoma </li></ul><ul><li>ASSOCIATION WITH SEVERE EMPHYSEMA (1 pt) </li></ul><ul><li>- 1 DLTx waiting-list </li></ul>
  • 50. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PAVIA CTEPH PROGRAM January, 1 st – June, 9 th 2011  145 pts New Evaluations (57 pts) PEAs FUP (69 pts) Clinical Trials (18 pts) DL/HLTx (1 pt) CONFIRMED (31 pts - 54%) OTHER DIAGNOSIS (26 pts - 46%) OPERABILITY RATE 94 % <ul><li>PROXIMAL LESIONS (29 pts) </li></ul><ul><li>- 29 PEAs (4 pts evaluated in 2010) </li></ul><ul><li>- 4 pts waiting for PEA </li></ul><ul><li>DISTAL LESIONS (2 pts) </li></ul><ul><li>- 2 medical therapy: 1 too old for DLTx </li></ul><ul><li>1 too early for DLTx </li></ul><ul><li>MISCELLANEOUS (25 pts) </li></ul><ul><li>TUMOR (1 pt) </li></ul><ul><li>- 1 pulmonary angiosarcoma </li></ul>
  • 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
  • 53. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE TRANSPLANT FOR CTEPH 18 / 79 MORE DIAGNOSIS MORE DISTAL PEAs
  • 54. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA POPULATION OF 357 PEAs
  • 55. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE RIGHT HEART CATHETERIZATION OF 357 PEAs
  • 56. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY OF 357 PEAs
  • 57. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY OF 357 PEAs <ul><li>Tricuspid regurgitation Absent 2.7% </li></ul><ul><li>Mild 18.9% </li></ul><ul><li>Moderate 29.7% </li></ul><ul><li>Severe 48.7% </li></ul><ul><li>Abnormal interventricular septal motion Yes 91.9% </li></ul><ul><li>No 8.1% </li></ul><ul><li>Inferior vena cava collapsibility Yes 40.5% </li></ul><ul><li>No 59.5% </li></ul>78.4%
  • 58. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY OF 357 PEAs
  • 59. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY
  • 60. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE OF 244 PEA
  • 61. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE OF 244 PEA
  • 62. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE
  • 63. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE LUNG FUNCTION OF 357 PEAs
  • 64. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ARTERIAL BLOOD GASES OF 357 PEAs
  • 65. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MODIFIED BRUCE TEST OF 357 PEAs
  • 66. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIOPULMONARY EXERCISE TESTING OF 200 PEAs
  • 67. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIOPULMONARY EXERCISE TESTING OF 200 PEAs
  • 68. <ul><li>Median sternotomy </li></ul><ul><li>Cardio Pulmonary Bypass </li></ul><ul><li>Moderate hypotermia (24 °C) </li></ul><ul><li>Circulatory arrest (7 min) </li></ul><ul><li>Reperfusion period (5 min) </li></ul><ul><li>Bilateral </li></ul>J Thorac Cardiovasc Surg 1993;106:116-27 PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PULMONARY ENDARTERECTOMY
  • 69. <ul><li>Intra-wall dissection </li></ul><ul><li>Peripheral extension </li></ul><ul><li>Explore all branches </li></ul>J Thorac Cardiovasc Surg 1993;106:116-27 PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PULMONARY ENDARTERECTOMY
  • 70. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL INSTRUMENT
  • 71. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PULMONARY ENDARTERECTOMY
  • 72. E.L. – 38 yrs M – Dec 1999 – PEA #42 mPAP 43  20 (-53%) CO 3.3  6.9 (+109%) PVR 994  220 (-78%) PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE TYPICAL SURGICAL SPECIMENS P.A. – 66 yrs M – Jun 2001 – PEA #60 mPAP 50  25 (-50%) CO 2.6  4.4 (+69%) PVR 1385  364 (-74%)
  • 73. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE DISTAL LESIONS JAMIESON TYPE III LEARNING CURVE
  • 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
  • 86. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UP STUDY <ul><li>To monitor the natural history of these pts after PEA in terms of: </li></ul><ul><ul><li>clinical status (by NYHA class) </li></ul></ul><ul><ul><li>hemodynamic (by right heart catheterization) </li></ul></ul><ul><ul><li>heart morphology and function (by ecocardiography and nuclear magnetic resonance) </li></ul></ul><ul><ul><li>lung function (by spirometry, carbon monoxide transfer factor, arterial blood gas) </li></ul></ul><ul><ul><li>exercise tolerance (by modified Bruce test and cardiopulmonary exercise testing) </li></ul></ul><ul><ul><li>anatomy of arterial pulmonary vascular branches (by perfusion scinti scan, pulmonary angiography, multi detector angio-CT scan) </li></ul></ul>
  • 87. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UP TIMING <ul><li>All pts underwent follow-up evaluation at: </li></ul><ul><ul><li>discharge (at this interval NYHA class, lung function, and exercise tolerance are excluded because pts are to close to the surgical procedure) </li></ul></ul><ul><ul><li>3 th month </li></ul></ul><ul><ul><li>yearly for 5 years </li></ul></ul><ul><ul><li>7 th , 10 th and 15 th year (10 controls) </li></ul></ul>
  • 88. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE NYHA FUNCTIONAL CLASS Pre-op 3m 1y 3y 5y 7y 10y p < 0.01
  • 89. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE mean PULMONARY ARTERY PRESSURE p < 0.01 Pre-op disch 3m 1y 3y 5y 7y 10y
  • 90. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PULMONARY VASCULAR RESISTANCES p < 0.01 Pre-op disch 3m 1y 3y 5y 7y 10y
  • 91. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY Before PEA
  • 92. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDOGRAPHY First echo after PEA – POD #9
  • 93. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY 3-months FUP after PEA
  • 94. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE Before PEA First CMR after PEA – POD #6
  • 95. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE 4-years FUP after PEA First CMR after PEA – POD #6
  • 96. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REVERSE RIGHT VENTRICULAR REMODELING
  • 97. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ARTERIAL OXYGEN PARTIAL PRESSURE p < 0.01 Pre-op 3m 1y 3y 5y 7y 10y
  • 98. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MODIFIED BRUCE TEST p < 0.01 Pre-op 3m 1y 3y 5y 7y 10y
  • 99. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE RESULTS <ul><li>The majority of pts experienced dramatic improvement in pulmonary hemodynamics after PEA </li></ul><ul><li>After PEA the decrease in pulmonary artery pressure is immediate (in O.R.) and associated with complete recovery of RV morphology (at discharge) </li></ul><ul><li>The functional results also show a progressive good recovery over a longer time (about years) </li></ul>
  • 100. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE RESULTS <ul><li>About 10-15% of our pts showed no statistically significant differences compared to pre-op or a persistent PH after PEA </li></ul><ul><li>About 5-10% of our pts showed a new increase in pulmonary pressure after PEA over time </li></ul><ul><li>The reason could be a secondary small vessel arteriopathy (Eisenmenger-type syndrome) in the non-obstructed segments of the lungs already present at the time of PEA </li></ul>
  • 101. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSION <ul><li>Poor survival rate of untreated pts (10% 5-yrs survival if mPAP  50 mmHg), low mortality rate after PEA and good mid- and long- term results confirm PEA as the procedure of choice for operable CTEPH pts </li></ul><ul><li>The improvement of functional capacity strictly depends on the hemodynamic changes after PEA </li></ul><ul><li>When CTEPH is diagnosed, given the natural history of the disease, patients should be referred for surgery even when in NYHA functional class II </li></ul>
  • 102. <ul><li>CTEPH pts should be referred early to Centres experienced in both PEA and Tx , to offer the best treatment and to achieve the best results </li></ul><ul><li>This strategy maximizes the use of scarce donor organs by offering, when feasible, a non-transplant option </li></ul>SURGICAL TREATMENT OF CTEPH: FROM TRANSPLANT TO CONSERVATIVE SURGERY CONCLUSION
  • 103. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PULMONARY ENDARTERECTOMY IN THE ELDERLY EXTENSION OF SURGICAL CRITERIA
  • 104. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AGE <ul><li>Apr 1994 – Dec 2002 -> 10.8 % (9/83) </li></ul><ul><li>Jan 2003 – June 2011 -> 31.8 % (87/274) </li></ul>Apr 1994 – June 2011 -> 357 PEAs 261 (73.0%) PEAs performed in patients < 70 years old 96 (27.0%) PEAs performed in patients ≥ 70 years old
  • 105. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AGE
  • 106. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CUMULATIVE PROPORTION SURVIVING OF 261 vs. 96 PEAs 90.9  2.2 86.9  3.0 88.5  2.6 89.3  2.5 85.0  3.5 85.0  3.5 81.2  5.7 78.0  6.3 78.0  6.3
  • 107. <ul><li>Age did not affect the efficacy of PEA: PVR dramatically and equally decreased in both groups </li></ul><ul><li>We never considered age as a contraindication to PEA </li></ul><ul><li>However, operative mortality and perioperative morbidity were higher in patients age 70 and older : Gram negative infections and reperfusion edema were more severe in the elderly </li></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSIONS
  • 108. <ul><li>Compared to young subjects, elderly patients had a higher prevalence of major preoperative comorbidities , were sicker at the time of operation and had a reduced functional reserve of their vital organs </li></ul><ul><li>However, this has to be expected in such patients: </li></ul><ul><ul><li>age is a well identified independent risk factor in cardiac surgery </li></ul></ul><ul><ul><li>in elderly patients the immune system response is less effective </li></ul></ul><ul><ul><li>antibiotic therapy may lead to renal and hepatic impairment, increasing morbility and mortality </li></ul></ul>PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSIONS
  • 109. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PAVIA PULMONARY ENDARTERECTOMY GROUP CTEPH <ul><li>Cardiac Surgery M Viganò, AM D’Armini, G Silvaggio, S Nicolardi, M Morsolini, G Mattiucci </li></ul><ul><li>Anestesiology M Maurelli, T Bianchi, R Veronesi, M Toscani, C Dezza, </li></ul><ul><li> E Milanesi, B Lusona, B Rossini </li></ul><ul><li>Cri tica l Care A Braschi, V Emmi, G Rodi, G Sala Gallini </li></ul><ul><li>F Capra Marzani, M Zanierato, F Mojoli </li></ul><ul><li>Cardiology L Oltrona Visconti, S Ghio, A Raisaro, L Scelsi, C Raineri </li></ul><ul><li>Respiratory Disease M Luisetti, I Cerveri, A Corsico </li></ul><ul><li>Radiology I R Dore </li></ul><ul><li>Radiology II F Zappoli Thyrion, P Quaretti, A Azzaretti, G Rodolico </li></ul><ul><li>Nuclear Medicine C Aprile </li></ul><ul><li>Reumatology C Montecucco, R Caporali </li></ul><ul><li>Thromboembolism F Piovella, M Barone, C Beltrametti </li></ul><ul><li>Pathology E Arbustini, M Grasso </li></ul><ul><li>General Rehabilitation E Dalla Toffola, L Petrucci </li></ul><ul><li>Pulmonary Rehabilitation C Fracchia, G Callegari </li></ul><ul><li>Biostatistics C Klersy </li></ul>

×