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PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
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PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE

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PULMONARY ENDARTERECTOMY : THE PAVIA EXPERIENCE

PULMONARY ENDARTERECTOMY : THE PAVIA EXPERIENCE

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  • 1. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE Andrea M D’Armini, MD, FCCP Division of Cardiac Surgery University of Pavia School of Medicine Foundation I.R.C.C.S. San Matteo Hospital Pavia - Italy UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 2. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INTRODUCTION• Chronic thromboembolic pulmonary hypertension (CTEPH) represents the only type of pulmonary hypertension surgically treatable, in the majority of cases, without transplant• This life-saving conservative surgery is called pulmonary endarterectomy (PEA) UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 3. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INTRODUCTION PEA vs. LTx • Elective surgery, non donor-dependent • No “transplant window” to be considered • Age is not a contraindication • Lower post-operative complications – early (acute graft failure, acute rejection, infections) – late (BOS, neoplasms, infections) • Outcome – post-operative long term survival – quality of life (back to normal) – steady functional improvementUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 4. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE EPIDEMIOLOGY• Epidemiologic data: in Italy ≈ 65.000 cases / year of acute symptomatic pulmonary embolism (PE)• Prevalence of CTEPH in pts surviving an acute PE (≈ 80 %) is calculated between 0.5% – 3.8% → up to 2.000 new cases / year• Considering asymptomatic pulmonary embolism and misdiagnosed pulmonary embolism, the true incidence of CTEPH may be even greater • Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg 2000; 37:165-252 • Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001; 345:1465-72 • 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 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 5. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CURRENT SITUATION• CTEPH is still under-diagnosed and nowadays only few physicians are aware of the surgical procedure called PEA• 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 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 6. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE NATURAL HISTORY • Pulmonary embolism (symptomatic / asymptomatic) • “Honeymoon” period: months / years • Hypertensive remodeling of the patent pulmonary vascular bed (Eisenmenger-like) • Right ventricle hypertrophy with progressive right heart deterioration right failure • Left ventricle compression with left heart functional impairmentUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 7. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE GENERAL CONDITIONS • Low cardiac output with dyspnea, cough, cyanosis, hepatomegaly, ascites, lower limb edema, syncope, hemoptysis and interscapular olosystolic murmur • Hypoxemia with exercise, sometimes at rest also • Frequent positive anamnesis for deep venous thrombosis and / or coagulative and immunologic disordersUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 8. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MARKED THROMBOPHILIA • A PERMANENT INFERIOR VENA CAVA FILTER was placed before PEA in the majority (376/410) of patients • Lifelong oral anticoagulation was prescribed after PEAUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 9. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 10. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 11. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 12. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 13. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE INDICATIONS FOR SURGERY• The indications for the surgical treatment of these patients are based on CLINIC HEMODYNAMIC• The indications for the type of surgery are based on ANATOMYUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 14. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CLINIC • Patients must be in NYHA functional class III or IV • Full anticoagulation for at least 3 months • Some Authors (we too) recently have performed PEA even in NYHA class II patients, given the natural history of the diseaseUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 15. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE HEMODYNAMIC• Pulmonary hypertension (mPAP 25 mmHg)• Causing low cardiac output• Resulting in calculated pulmonary vascular resistances (PVR) > 300 dyne*sec*cm-5UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 16. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE HEMODYNAMIC • In some cases this calculation [PVR = (mPAP – Wedge) / CO * 80] could result in a value < 300 dynes*sec*cm-5 due to a partially maintained CO ( 3.5 L/min) or for a inaccurate measurement of wedge pressure (high value for extensive collateral bronchial arteries flow) • In these cases the leading variable is the degree of pulmonary hypertension (mPAP 25 mmHg at rest)UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 17. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ANATOMY • The surgical treatment depends on the localization of the lesions in the pulmonary arterial branches • Lesions can be classified as PROXIMAL DISTALUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 18. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PROXIMAL LESIONSUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 19. 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 1766UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 20. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE DISTAL LESIONSUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 21. 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 1120UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 22. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OPERABILITY ASSESSMENT Which lesions have to be considered as inoperable?• Different operability assessments from different Centers• Growing single surgeon’s experience due to learning curve UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 23. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE BACKGROUND• PEA is the treatment of choice for patients with CTEPH• About only 10-15 Centers worldwide are performing PEA on a routine basis• In expert hands, mortality ranges between 5% and 12% and technical failure is below 8%• Early hemodynamic results are known to be excellent in case of successful operation UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 24. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REFERENCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 25. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE OUR PROGRAM • National referral program • Begin: April 1994 • To date: 410 PEAs performedUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 26. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PATIENTS’ REFERRAL OF 410 PEAs 12 2 8 113 22 Pavia 62 21 Pts coming from outside Italy 19 - Greece 1 30 - Kosovo 1 5 - U.S.A. 1 7 - Uganda 1 5 24 3 20 19 8 3 ≤ 15 pts 16 – 30 pts 6 ≥ 31 pts 19UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 27. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE NUMBER OF PEAs / YEAR OF 410 PEAsUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 28. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS OF 410 PEAs 2009-2011: 60 PEAs / yrUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 29. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS OF 410 PEAs 2008-2011 (4 yrs): 211 PEAs 1994-2007 (14 yrs): 174 PEAsUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 30. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS NEW EVALUATIONS 120 100 80 108Patients 60 40 54 20 0 2004 2010UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 31. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS DIAGNOSTIC ACCURACY 90 80 76% 70 60 50Patients IPCTE 40 82 Other 63% 30 20 34 26 10 20 0 2004 2010UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 32. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS OPERABILITY RATE 80 89% 70 60 50Patients 40 73 Operable Inoperable 30 74% 20 10 25 9 9 0 2004 2010UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 33. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AMOUNT OF PATIENTS PEAs PERFORMED 70 60 50 40 65PEAs 30 20 10 22 0 2004 2010UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 34. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA EXPERT CENTERUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 35. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA EXPERT CENTERUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 36. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MAIN WORLD PEA CENTERS Cambridge, UK ≈80 PEAs / year NATIONAL REFERRAL PROGRAM BY LAW Bad Nauheim, Germany ≈50 PEAs / year MORE THAN ONE PROGRAMSan Diego, California, USA ≈130 PEAs / year Pavia, ItalyNATIONAL REFERRAL PROGRAM ≈60 PEAs / year FOR EXCELLENCE MORE THAN ONE PROGRAM Paris, France ≈100 PEAs / year NATIONAL REFERRAL PROGRAM FOR EXCELLENCE UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 37. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE PEA POPULATION OF 410 PEAs Age 58 16 (11 84) years Gender 195 M – 215 F NYHA class 43 II – 188 III – 179 IV Length III / IV 19 23 months Urgent / Emergent 81 / 410 Oxygen therapy 194 / 410UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 38. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHYUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 39. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCEUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 40. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MODIFIED BRUCE TEST OF 410 PEAs Steps Walking distance No (Pa O2 < 60) 42.6% 183 ± 160 (8 – 852) meters Step 0 - ½ 47.5% Step 1 - 2 8.2% Step 3 - 4 1.6%UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 41. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEPULMONARY ENDARTERECTOMY • Median sternotomy • Cardio Pulmonary Bypass • Moderate hypotermia (24 C) • Circulatory arrest (7 min) • Reperfusion period (5 min) • Bilateral J Thorac Cardiovasc Surg 1993;106:116-27UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 42. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEPULMONARY ENDARTERECTOMY • Intra-wall dissection • Peripheral extension • Explore all branches J Thorac Cardiovasc Surg 1993;106:116-27UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 43. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL TIPS• Deep-moderate hypothermic circulatory arrest - meticulous dissection into a bloodless field (for optimal hemodynamic result)• Unclamped aorta - avoidance of aortic manipulation (reduction of cerebral events)• Hypothermic cardiac protection - ventricular fibrillation induced by hypothermia - ventricular fibrillation induced by device (fibrillator) - avoidance of cardioplegia administrationUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 44. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL TIPS• Changing features of CTEPH patients - population is rapidly aging, and an increasing number of elderly patients are referred for PEA - due to the continuous surgeon’s learning curve, the crucial border between operable and inoperable patients has been pushed more and more distally over time CTEPH patients are getting more frail and complex UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 45. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENT• Original San Diego technique - a single (20 min) deep hypothermic (18 C) total circulatory arrest for each side• Recent advances - short periods (5 – 7 min) of intermittent moderate hypothermic (24 C) circulatory arrest - followed by short periods of reperfusion ( 5 min) - with cerebral near-infrared spectroscopy (NIRS) monitoringUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 46. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCECEREBRAL PROTECTION STRATEGY NIRS MONITORING Near-InfraRed Spectroscopy CPB start 100 80 Patient’s cooling 60 SrO2 40 Pre-HCA baseline 20 HCA maximum drop 0 9.03.15 9.20.53 9.39.01 9.56.48 10.14.55 10.33.14 10.51.24 11.09.32 11.29.10 11.47.13 12.05.15 12.23.17 12.41.20 12.59.23 13.17.26 13.35.30 13.53.34 14.11.37 14.29.39 14.47.42 15.05.45 15.23.48 15.41.52 15.59.54 16.18.27 16.36.26 16.54.23 17.12.20 Reperfusion Time Changing PEA side Right channel End of PEA Left channel UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 47. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENT • 1st step - short periods (10 – 15 min) of intermittent deep hypothermic (18 ° C) circulatory arrest followed by short periods of reperfusion ( 5 min) with cerebral near-infrared spectroscopy (NIRS) monitoring • 2nd step - moderate (24 ° C) instead of deep hypothermic circulatory arrest • 3rd step - shorter periods (5 – 7 min) of intermittent circulatory arrest • to reduce invasiveness • to get more time to perform PEA in a bloodless surgical fieldUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 48. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENT OF 410 PEAs • Group A (83 pts) - original San Diego technique (but unclamped aorta) • Group B (70 pts) - short periods (10 – 15 min) of intermittent deep hypothermic (18 ° C) circulatory arrest followed by short periods of reperfusion ( 5 min) with cerebral near-infrared spectroscopy (NIRS) monitoring • Group C (91 pts) - moderate (24 ° C) instead of deep hypothermic circulatory arrest • Group D (166 pts) - shorter periods (5 – 7 min) of intermittent circulatory arrestUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 49. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENTUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 50. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENTUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 51. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENTUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 52. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENT Postoperative respiratory function and outcomeUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 53. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CPB MANAGEMENT Despite - patients are getting older - PEA surgery has become more complex due to Jamieson type III lesions - moderate (24 C) instead of deep (18 C) hypothermia - longer total circulatory arrest time Intermittent circulatory arrest under NIRS monitoring seems to enhance cerebral protection during PEA allowing for safe prolonged total circulatory arrest time and improving postoperative outcomesUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 54. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE SURGICAL INSTRUMENTUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 55. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEPULMONARY ENDARTERECTOMYUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 56. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE TYPICAL SURGICAL SPECIMENS E.L. – 38 yrs M – Dec 1999 – PEA #42 mPAP 43 20 (-53%) CO 3.3 6.9 (+109%) PVR 994 220 (-78%) P.A. – 66 yrs M – Jun 2001 – PEA #60 mPAP 50 25 (-50%) CO 2.6 4.4 (+69%) PVR 1385 364 (-74%)UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 57. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE LEARNING CURVE DISTAL LESIONS JAMIESON TYPE IIIUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 58. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEJAMIESON TYPE I vs. TYPE II vs. TYPE IIIL.M.E.L. - 65 yrs M - Oct 2004 - PEA #119mPAP 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%) UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 59. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCECUMULATIVE PROPORTION SURVIVING OF 410 PEAs 1,0 296 238 182 140 119 103 88 68 50 42 32 31 24 18 9 3 3 2 0,9 90.0% 88.3% 0,8 87.1% 86.4% 84.8% Cumulative Proportion Survival 0,7 83.0% 81.1% 79.5% 77.6% 74.7% 0,6 0,5 0,4 Hospital mortality 0,3 Global 39/410 (9.5%) WHO II 0/43 (0.0%) WHO III 12/186 (6.5%) 0,2 WHO IV 27/181 (14.9%) 0,1 Jan 08 – May 12 18/236 (7.6%) Jan 11 – May 12 6/82 (7.3%) 0,0 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 192 204 216 228 Months UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 60. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UPIn literature few data are reported on mid- and long- termcardiopulmonary function, particularly on exertion, and onclinical outcomes after PEAUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 61. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UP TIMING• All pts underwent follow-up evaluation at: – discharge (at this interval NYHA class, lung function, and exercise tolerance are excluded because pts are to close to the surgical procedure) – 3th month – yearly for 5 years – 7th, 10th and 15th year (10 controls) UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 62. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE FOLLOW-UP DATA• Seventeen of 368 pts (4.6%) do not participate to the long- term follow-up study since the beginning (2/4 pts referred from outside Italy) or at various intervals• For these pts we obtain data on survival and WHO functional class annually by scheduled phone-calls• All the other pts (95.4%) actively participate to the study UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 63. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE NYHA FUNCTIONAL CLASS NYHA Functional Class 100 90 80 70% patients 60 I-II 50 III-IV 40 30 20 10 0 Pre-op Pre-op 3 3m mesi 1y 1 anno 3y 3 anni 5 5y anni 7 7y anni 10y 10 anni Follow-up p < 0.01 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 64. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEmean PULMONARY ARTERY PRESSURE mean Pulmonary Arterial Pressure 60 50 40mmHg 30 20 10 0 Pre-op Pre-op disch Dimiss 3m 3 mesi 1y 1 anno 3y 3 anni 5y 5 anni 7y 7 anni 10 10y anni Follow-up p < 0.01 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 65. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEPULMONARY VASCULAR RESISTANCES Pulmonary Vascular Resistances 1200 1000dyne*sec*cm-5 800 600 400 200 0 Pre-op Pre-op Dimiss disch 3 mesi 3m 1 anno 1y 3 anni 3y 5 anni 5y 7 anni 7y 10 10y anni Follow-up p < 0.01 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 66. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY Before PEAUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 67. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDOGRAPHY First echo after PEA – POD #9UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 68. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE ECHOCARDIOGRAPHY 3-months FUP after PEAUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 69. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCE Before PEA First CMR after PEA – POD #6UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 70. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CARDIAC MAGNETIC RESONANCEFirst CMR after PEA – POD #6 4-years FUP after PEA UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 71. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE REVERSE RIGHT VENTRICULAR REMODELINGUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 72. PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING REVERSE RIGHT VENTRICULAR REMODELINGUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 73. PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING REVERSE RIGHT VENTRICULAR REMODELINGUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 74. PULMONARY ENDARTERECTOMY: REVERSE RIGHT VENTRICULAR REMODELING REVERSE RIGHT VENTRICULAR REMODELINGUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 75. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCEARTERIAL OXYGEN PARTIAL PRESSURE Arterial Oxygen Partial Pressure 100 90 80 70 60 mmHg 50 40 30 20 10 0 Pre-op Pre-op 3 3m mesi 1 anno 1y 3 3y anni 5 anni 5y 7 anni 7y 10 anni 10y Follow-up p < 0.01 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 76. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE MODIFIED BRUCE TEST Modified Bruce Test 1000 900 800 700 600meters 500 400 300 200 100 0 Pre-op Pre-op 3 3m mesi 1 anno 1y 3 anni 3y 5 anni 5y 7 7y anni 1010y anni Follow-up p < 0.01 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 77. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE RESULTS• The majority of pts experienced dramatic improvement in pulmonary hemodynamics after PEA• After PEA the decrease in pulmonary artery pressure is immediate (in O.R.) and associated with complete recovery of RV morphology (at discharge)• The functional results also show a progressive good recovery over a longer time (about years) UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 78. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE RESULTS• About 5% of our pts failed to showed a decrease > 20% in PVR compared to pre-operative value• About 8-10% of our pts showed a new increase in pulmonary pressure after PEA over time• 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 UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 79. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSION• 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• The improvement of functional capacity strictly depends on the hemodynamic changes after PEA• When CTEPH is diagnosed, given the natural history of the disease, patients should be referred for surgery even when in NYHA functional class II UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 80. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE EXTENSION OFPULMONARY ENDARTERECTOMY SURGICAL CRITERIA IN THE ELDERLYUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 81. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AGE Patients older than 70 years • Apr 1994 – Dec 2002 → 10.8 % (9/83) • Jan 2003 – May 2012 → 32.1% (105/327)UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 82. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE AGE 100% 80% 60% >= 70 yrs < 70 yrs 40% 20% 0% 1994-1998 1999-2003 2004-2008 2009-2011UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 83. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE STUDY POPULATION Apr 1994 – May 2012 → 410 PEAs 296 (72.2%) PEAs performed in patients < 70 years old 114 (27.8%) PEAs performed in patients ≥ 70 years old Two distinct populations were therefore identified according to age (<70 yrs or ≥70 yrs) and described by – pre-operative variables – operative and post-operative variablesUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 84. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCECUMULATIVE PROPORTION SURVIVING OF 296 vs. 114 PEAs 1.0 126 112 101 87 69 53 42 34 30 23 15 9 4 4 2 0.9 90.9 2.2 89.3 2.5 81.2 5.7 88.5 2.6 86.9 3.0 85.0 3.5 85.0 3.5 78.0 6.3 78.0 6.3 0.8 29 19 15 10 6 4 4 2 2 2 2 1 1 0.7 0.6 Percentage 0.5 0.4 0.3 0.2 0.1 0.0 < 70 yrs 0 12 24 36 48 60 72 84 96 108 120 132 144 156 168 180 >= 70 yrs Months after PEA UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 85. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSIONS • Age did not affect the efficacy of PEA: PVR dramatically and equally decreased in both groups • We never considered age as a contraindication to PEA • 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 elderlyUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 86. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSIONS• 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• However, this has to be expected in such patients: – age is a well identified independent risk factor in cardiac surgery – in elderly patients the immune system response is less effective – antibiotic therapy may lead to renal and hepatic impairment, increasing morbility and mortalityUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 87. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE CONCLUSIONSNew surgical strategies have been adopted in order toreduce invasiveness in the frail elderly: – prefer moderate (24-26 °C) to deep (16-18 °C) hypothermia – perform shorter circulatory arrests (7-9 min vs. 20 min) – effective prophylaxis of infections (intra-operative BAL) – refer elderly patients to a rehabilitation Center before PEA to improve their vital organs functional reserve and to gain a better functional status at the time of operation (notably for COPD)UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 88. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE EXTENSION OFPULMONARY ENDARTERECTOMY SURGICAL CRITERIA IN WHO FUNCTIONAL CLASS II UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 89. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II Population 43 PEAs out of 410 (10.5 %) from Apr 1994 to May 2012 Hospital mortality 0 % Main patients’ features“couch potatoes” “sportsmen” 53.5 % (23/43) 46.5 % (20/43)UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 90. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II Population Wide spectrum of clinical presentationsUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 91. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II Results Postoperative outcomeUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 92. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II Results Postoperative outcomeUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
  • 93. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE WHO FUNCTIONAL CLASS II Results• Given the natural history of the disease we perform PEA even in NYHA functional class II patients• Once CTEPH is diagnosed, there is no reason to delay surgery: – CTEPH is associated with a progressive vascular remodeling of the unobstructed branches (Eisenmenger) – outcome after PEA in NYHA II patients is excellentUNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY

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