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CTEPH CASI CLINICI
1. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
P. F. #255
XX-XX-1949
ITALIAN
VARESE
HOUSE PAINTER
150 cm
48 Kg
Systemic arterial hypertension
Gastroesophageal reflux disease
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
2. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
JUNE 2004
Onset of mild dyspnea (WHO II)
JUNE 2005
Worsening of dyspnea (WHO III)
JULY 2005
Admission to the Cardiology ward of a local hospital
• ECG: right ventricle overload
• Echocardiogram: dilation and hypokinesia of the right chambers
severe tricuspid regurgitation
CTEPH
severe pulmonary hypertension (sPAP 85 mmHg)
• Lung V/Q scan: bilateral mismatches with multiple perfusion defects
• HRCT scan: multiple bilateral segmental perfusion defects
• Venous echocolordoppler of lower limbs : negative
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
3. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
SEPTEMBER 2005
Admission to our Division for operability assessment
• COMPLETE DIAGNOSTIC WORKUP: CTEPH CONFIRMED
• Right Heart Catheterization: RA 1 mmHg
RV 82 / 0 mmHg
PA 82 / 39 / 13 mmHg
PCWP 3 mmHg
CO 3.3 L/min
CI 2.2 L/min
RVEF 25 %
PVRP 873 dyn*s*cm-5
• OPERABILITY: INOPERABLE FOR EXCLUSIVELY DISTAL DISEASE
DOUBLE LUNG TRANSPLANT WAITING LIST
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
4. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
LUNG V/Q SCAN
VENTILATION PERFUSION
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
5. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
PULMONARY ANGIOGRAM
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
6. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
HRCT SCAN
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
7. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
DECEMBER 2005
Enrollment in the BENEFIT study
(bosentan vs. placebo in inoperable forms of CTEPH)
INOPERABILITY CONFIRMED BY THE INTERNATIONAL COMMITTEE
Enrollment End of study (16 weeks) Open label extension
27-DEC-2005 28-APR-2006 26-OCT-2006
RA 4 4 6 mmHg
RV 82/2 82/0 85/3 mmHg
PA 82/46/24 82/45/22 85/49/28 mmHg
PCWP 5 5 5 mmHg
CO 3.1 2.4 3.0 L/min
CI 2.1 1.6 2.0 L/min/m2
RVEF 34 11 12 %
PVR 1057 1343 1164 dyn*s*cm-5
Serum-BNP 360 324 151 pg/ml
WHO III III II
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
8. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
BENEFIT and BENEFIT-OPEN LABEL EXTENSION
Clinical course
6mWT
15-FEB-2008 Withdrawal from DLTx waiting list
600
480
456 462
500 442
418
400
meters
290
270
300
200
WHO III WHO II
100
BENEFIT BENEFIT-Open Label
0
Dec-05 Apr-06 Oct-06 May-07 Oct-07 May-08 Jan-09
Follow-up
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
9. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
OCTOBER 2009
Worsening of dyspnea (back to WHO III)
NOVEMBER 2009
Admission to our Division for therapy update
NEW OPERABILITY ASSESSMENT → NOW TECHNICALLY OPERABLE
(JUST ALIKE THE PREVIOUS FINDINGS)
BILATERAL PULMONARY ENDARTERECTOMY
Right: upper, middle and lower lobe
Left: upper lobe, lingula and lower lobe
Moderate hypothermia (23 C)
Intermittent circulatory arrests right side: 91 min
left side: 47 min
total time: 138 min
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
10. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
BILATERAL PEA – SURGICAL SPECIMEN
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
11. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
BILATERAL PEA
Early postoperative outcome
• Invasive mechanical ventilation < 24 h
• Assisted normal breathing with continuous positive pressure (cPAP)
(to avoid reperfusion lung edema)
• ICU stay: 2 days (fast-track recovery program)
• Total postoperative hospital stay: 16 days
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
12. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
A peculiar case: a “seasoned veteran” in CTEPH
BILATERAL PEA
Hemodynamic results
Preoperative At discharge 3 months FUP
27-NOV-2009 15-DEC-2009 26-FEB-2010
RA 7 3 3 mmHg
RV 120/0 53/0 35/0 mmHg
PA 120/65/36 53/22/8 35/19/12 mmHg
PCWP 5 5 5 mmHg
CO 3.5 3.9 4.2 L/min
CI 2.4 2.7 2.9 L/min/m2
RVEF 6 18 21 %
PVR 1371 308 267 – 81 % dyn*s*cm-5
Serum-BNP 996 742 106 pg/ml
WHO III I I
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
13. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
JAMIESON TYPE III
The “seasoned veteran”
SPECIFIC
MEDICAL
THERAPY PULMONARY
ENDARTERECTOMY
TRANSPLANT (Gold Standard)
WAITING LIST
SPECIFIC PAH-DRUG
DISCONTINUATION
DIAGNOSIS
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
14. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
P. B. #250
XX-XX-1934 (75 y)
ITALIAN
TURIN
PENSIONER
178 cm
72 Kg
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
15. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
MEDICAL HISTORY
• Congenital single kidney (right)
• Sigmoid diverticulosis
• Bilateral cataract
• 2000: colonscopy polyp removal
SEPTEMBER 2009
Onset of mild dyspnea (WHO II) and right thoracic pain
OCTOBER 2009
Acute dyspnea (WHO IV) → admission to the Emergency Ward
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
16. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
OCTOBER 2009
Emergency ward diagnostic workup
• ECG: right ventricle overload
• Echocardiogram:
CTEPH
dilation and hypokinesia of the right chambers
paradoxical movement of the interventricular septum
severe tricuspid regurgitation
severe pulmonary hypertension (sPAP 90 mmHg)
• HRCT scan: multiple bilateral segmental perfusion defects
NOVEMBER 2009
Admission to our Division for operability assessment
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
17. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
THROMBOPHILIA AND HYPERCOAGULABILITY
Laboratory findings
• Hyperhomocysteinemia
• Excess Factor VIII
• Prothrombin gene mutation (G20210A – Factor II)
• Homocysteine methabolism gene mutation (C677T – MTHFR)
• Homocysteine methabolism gene mutation (A1298C – MTHFR)
Echocolordoppler of the lower limbs
• Previous bilateral deep venous thrombosis
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
18. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
OPERABILITY ASSESSMENT
Lung V/Q scan
• Massive bilateral perfusion defects
(mainly at left upper lobe, lingula and right upper lobe)
• Quantitative perfusion map: left 38% – right 62%
Pulmonary angiogram
• Right upper lobe occlusion
• Right inferior segmental middle lobe occlusion
• Right posterior segmental lower lobe occlusion
• Left anterior and posterior segmental upper lobe occlusion
• Left lower lobe occlusion
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
19. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
OPERABILITY ASSESSMENT
HRCT scan
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
20. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
OPERABILITY ASSESSMENT
Hemodynamic
Preoperative
06-NOV-2009
RA 2
RV 78/0
PA 78/38/15
PCWP 5
CO 4.4
CI 2.3
RVEF 36
PVR 600
Serum-BNP 70
WHO III
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
21. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
COLLATERAL FINDINGS
Echocolordoppler of the neck vessels
• 55% right common – internal carotid artery stenosis
• 65% left common – internal carotid artery stenosis
Coronary angiogram
• Left main coronary artery ostial stenosis (80%)
• LAD, 1st Diagonal, 2nd Diagonal and Circumflex stenosis
• Normal right coronary artery
Echocardiogram
• Moderate aortic regurgitation
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
22. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
OPERATION
BILATERAL PULMONARY ENDARTERECTOMY
Right: upper, middle and lower lobe
Left: upper lobe, lingula and lower lobe
Moderate hypothermia (24 C)
Intermittent circulatory arrests right side: 50 min
left side: 30 min
total time: 80 min
CORONARY ARTERY BYPASS GRAFTING
Right great saphenous vein on LAD and Circumflex
AORTIC VALVE REPLACEMENT
Carpentier-Edwards® Aortic Porcine Bioprosthesis
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
23. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
BILATERAL PEA – SURGICAL SPECIMEN
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
24. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
BILATERAL PEA
Early postoperative outcome
• Invasive mechanical ventilation < 24 h
• Assisted normal breathing with continuous positive pressure (cPAP)
(to avoid reperfusion lung edema)
• ICU stay: 2 days (fast-track recovery program)
• Total postoperative hospital stay: 10 days
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
25. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
PEA IN THE ELDERLY
A peculiar case
BILATERAL PEA
Hemodynamic results
Preoperative At discharge 3 months FUP
06-NOV-2009 18-NOV-2009 18-FEB-2010
RA 2 3 5 mmHg
RV 78/0 26/0 30/0 mmHg
PA 78/38/15 26/11/5 30/18/9 – 53 % mmHg
PCWP 5 5 5 mmHg
CO 4.4 4.2 4.9 + 11 % L/min
CI 2.3 2.2 2.7 L/min/m2
RVEF 36 40 36 %
PVR 600 114 212 – 65 % dyn*s*cm-5
Serum-BNP 70 186 66 pg/ml
WHO III I I
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
26. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
T. S. #108
XX-XX-1983
ITALIAN
GENOA
STUDENT
162 cm
79 Kg
Thrombosis risk factors
Sedentary lifestyle
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
27. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MEDICAL HISTORY
• Obesity (BMI > 30 kg/m2) – Hormonal contraception – Active smoker ( 20 cig / day)
• Recent car accident injuries without adequate venous thromboembolism prophylaxis
• Coagulative disorders (hyperhomocysteinemia with C677T and A1298C gene mutation,
excess plasminogen activator inhibitor)
NOVEMBER 2003
Acute pulmonary embolism
THROMBOLYSIS
Right: partial embolic obstruction of the main pulmonary artery
Left: total embolic occlusion of the main pulmonary artery
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
28. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
APRIL 2004
HRCT scan
Despite thrombolysis and 6 months of full oral anticoagulation therapy
Right: patent pulmonary artery
Left: persisting subtotal embolic obstruction of the main pulmonary artery
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
29. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
APRIL 2004
Complete diagnostic workup
LUNG V/Q SCAN
VENTILATION PERFUSION
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
30. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
APRIL 2004
Complete diagnostic workup
HEMODYNAMIC
Preoperative
07-APR-2004
RA 6
RV 33/0
PA 29/20/12
PCWP 4
CO 6.7
CI 3.6
RVEF 55
PVR 191
Serum-BNP 20
WHO II
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
31. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
APRIL 2004
Complete diagnostic workup
PULMONARY ANGIOGRAM
• Radiologic features
• Failure of anticoagulation on the left obstruction
• Normal hemodynamic despite severe perfusion defect
DIFFERENTIAL DIAGNOSIS
LEFT PULMONARY ARTERY ANGIOSARCOMA ?
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
32. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
APRIL 2004
Complete diagnostic workup
DIFFERENTIAL DIAGNOSIS
LEFT PULMONARY ARTERY ANGIOSARCOMA ?
INTRAVASCULAR BIOPSY
• Unfortunately unsuccessful
• Undetermined diagnosis
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
33. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
LEFT UNILATERAL PEA – INTRAOPERATIVE DIAGNOSIS
• At surgical inspection the endoluminal material
appeared to be thromboembolic
• A left unilateral PEA was performed
• Diagnosis confirmed by histological examination
• Uncomplicated postoperative recovery
Invasive Mechanical Ventilation < 24 h
ICU stay 2 days
Total postoperative hospital stay 8 days
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
34. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
LEFT UNILATERAL PEA
Hemodynamic results
Preoperative At discharge
07-APR-2004 26-APR-2004
RA 6 3 mmHg
RV 33/0 29/0 mmHg
PA 29/20/12 29/13/2 – 35 % mmHg
PCWP 4 5 mmHg
CO 6.7 7.5 + 12 % L/min
CI 3.6 4.1 L/min/m2
RVEF 55 53 %
PVR 191 85 – 55 % dyn*s*cm-5
Serum-BNP 20 91 pg/ml
WHO II I
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
35. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
DISCUSSION
• The hospitalization due to car accident injuries may have been complicated
by a left pulmonary thromboembolism
• The patient could have been asymptomatic because of her sedentary lifestyle
• A second acute pulmonary thromboembolism on the right side could have
revealed the previously asymptomatic disease
• Even if oral anticoagulation relieved most of symptoms and hemodynamic
was normal, we deemed the patient a potential candidate for PEA
• The aim was to prevent the inexorable evolution of chronic thromboembolic
lesions into CTEPH with vascular remodeling of the patent branches
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
36. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
P. G. #146
XX-XX-1944
ITALIAN
CREMONA
SPORTSMAN
180 cm
83 Kg
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
37. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MEDICAL HISTORY
• 1996: onset of exertional angina (negative cardiopulmonary exercise test)
• 2001: acute pulmonary embolism → oral anticoagulation therapy
• 2002 → 2006: regular echocardiographic controls showing the progressive onset of PH
• 2006: onset of exertional dyspnea (WHO II)
MAY 2006
Admission to our Division for operability assessment
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
38. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MAY 2006
Complete diagnostic workup
LUNG V/Q SCAN
VENTILATION PERFUSION
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
39. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MAY 2006
Complete diagnostic workup
HEMODYNAMIC
Preoperative
11-MAY-2006
RA 4
RV 84/3
PA 84/45/20
PCWP 5
CO 2.9
CI 1.4
RVEF 18
PVR 1103
Serum-BNP 140
WHO II
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
40. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MAY 2006
Complete diagnostic workup
PULMONARY ANGIOGRAM
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
41. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
MAY 2006
Complete diagnostic workup
HRCT SCAN
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
42. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
BILATERAL PEA – SURGICAL SPECIMEN
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
43. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
BILATERAL PEA
Hemodynamic results
Preoperative At discharge 4 years FUP
11-MAY-2006 26-MAY-2006 12-MAR-2010
RA 4 0 5 mmHg
RV 84/3 15/0 29/0 mmHg
PA 84/45/20 15/12/6 29/18/9 – 60 % mmHg
PCWP 5 3 5 mmHg
CO 2.9 3.9 4.5 – 55 % L/min
CI 1.4 2.0 2.3 L/min/m2
RVEF 18 25 39 %
PVR 1103 185 231 – 79 % dyn*s*cm-5
Serum-BNP 140 82 12 pg/ml
WHO II I I
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY
44. PULMONARY ENDARTERECTOMY: THE PAVIA EXPERIENCE
WHO FUNCTIONAL CLASS II
A peculiar case
DISCUSSION
• Anticoagulation after the acute pulmonary embolism was probably
not completely effective
• The incomplete resolution of organized pulmonary emboli resulted
in progressive right heart failure
• Due to his high exercise tolerance, the patient became symptomatic
only when the severe pulmonary hemodynamic jeopardized the left
heart function (cardiac index of 1.4 L/min/m2)
• Hemodynamic and radiologic features of the disease were both
impressive despite paucity of symptoms
UNIVERSITY OF PAVIA SCHOOL OF MEDICINE - SAN MATTEO HOSPITAL - PAVIA - ITALY