Non-invasive follow-up strategy after pulmonary endarterectomy for CTEPH

Background The success of pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) is usually evaluated by performing a right heart catheterisation (RHC). Here, we investigate whether residual pulmonary hypertension (PH) can be sufficiently excluded without the need for a RHC, by making use of early postoperative hemodynamics, or NT-proBNP, cardiopulmonary exercise testing (CPET) and transthoracic echocardiography (TTE) 6 months after PEA.

Methods In an observational analysis, residual PH after PEA measured by RHC was related to hemodynamic data from the postoperative ICU time and data from a 6-month follow-up assessment including NT-proBNP, TTE and CPET. After dichotomisation and univariate analysis, sensitivity, specificity, positive predictive value, negative predictive value (NPV) and likelihood ratios were calculated.

Results Thirty-six out of 92 included patients had residual PH 6 months after PEA (39%). Correlation between early postoperative and 6-month follow-up mean pulmonary artery pressure was moderate (Spearman rho 0.465, p<0.001). Early hemodynamics did not predict late success. NT-proBNP>300 ng L⁻¹ had insufficient NPV (0.71) to exclude residual PH. Probability for PH on TTE had a moderate NPV (0.74) for residual PH. Peak oxygen consumption (VO₂)<80% predicted had the highest sensitivity (0.85) and NPV (0.84) for residual PH.

Conclusions CPET 6 months after PEA, and to a lesser extent TTE can be used to exclude residual CTEPH, thereby safely reducing the number of patients needing to undergo re-RHC after PEA.