Long-term effects of medical therapy pre- and post-pulmonary endarterectomy-insights from the UK CURATE registry.

INTRODUCTION

Pulmonary endarterectomy (PEA) is recommended in patients with proximal chronic thromboembolic pulmonary hypertension (CTEPH). However, there is limited and conflicting evidence regarding the use of PH medical therapy as a bridge to PEA. Similarly, there is no consensus on the criteria for continuing or restarting PH medical therapy postoperatively. We assessed the characteristics and long-term outcome of patients receiving PH bridging therapy and identified characteristics of residual PH post-PEA.

METHODS

We conducted a secondary analysis of the prospective CURATE registry, evaluating the UK's national CTEPH cohort undergoing PEA between January 1, 2015 and December 12, 2022. Characteristics associated with pre-PEA bridging therapy, post-PEA PH-medical therapy, and long-term outcome were assessed.

RESULTS

About 1102 patients underwent PEA, of which 661 (60%) received bridging therapy. Patients treated with bridging therapy had higher mPAP (46 vs 44 mmHg, p = 0.038) and worse functional class (NYHA III 84% vs 76%, p = 0.003) at baseline and showed lower 1- and 3-year survival (93% vs 96% and 89% vs 94%, p = 0.002). Post-PEA, 47% of PEA patients had elevated postoperative mPAP of ≥25mmHg. mPAP >31 mmHg and PVR >336dynes.sec.cm-5 were associated with the initiation of post-PEA PH medical therapy.

CONCLUSION

After adjustment for 6MWD, no survival difference was observed between patients treated with PH medical therapy pre-PEA and patients who were not treated. Residual PH defined as mPAP ≥25mmHg affects 47%, however, only 15% of patients receive PH medical therapy post-PEA. As uncertainties remain, further studies are needed to evaluate decision-making for medical PH therapy pre-PEA and for treatment of residual PH.