Ann Thorac Surg 2002;74:184
© 2002 The Society of Thoracic Surgeons
Original article: general thoracic
Invited commentary
Hans-Joachim Schäfers, MDa
a Department of Thoracic and Cardiovascular Surgery, University of Saarland Kirrberger Str. Homburg/Saar D-66421, Germany
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 Introduction
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Pulmonary thromboendarterectomy has been shown to be a very effective treatment option for patients with thromboembolic pulmonary hypertension. It drastically reduces pulmonary vascular resistance and markedly improves right ventricular function and exercise ability.
Despite increasing experience, a number of questions remain in conjunction with this operation. Patient selection for this treatment as opposed to lung transplantation still involves subjective decision criteria. The early postoperative course is characterized by marked hemodynamic instability and increased vasopressor support, indicating the action of systemic factors such as cytokines that in this disease appear to have a more pronounced effect than in other areas of cardiac surgery. The exact pathomechanism still needs to be elucidated. While PTE has obvious advantages over lung transplantation, only limited long-term data have been published after surgical desobliteration of the pulmonary arterial tree. The information that is available is mostly limited to survival and NYHA stage which are very crude parameters. In the process of generating hemodynamic follow-up data, we have in some patients found a marked discrepancy between persistent pulmonary hypertension and their (subjective) NYHA class. Thus, more objective (and possibly non-invasive parameters) are needed.
The current investigation by Nagaya and coworkers is one step in this direction. It still leaves a number of questions. In view of the correlation between BNP and pulmonary artery pressure and resistance, could it be used as a prognostic indicator in preoperative decision-making? What are the reasons for the limited sensitivity and specificity of BNP as a predictor for persistent PHT? How marked would the effect of concomitant left heart failure be? Much more information will be needed until we understand the physiology of the disease better, which will hopefully aid us in choosing our treatment options better and refine them further.
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