Abstract
Operability assessment in CTEPH remains highly subjective. In order to provide the optimal care to each patient with CTEPH, we encourage direct evaluation and counselling whenever possible. http://ow.ly/uRCO30mMs46
From the authors:
We thank R. Condliffe and co-workers for their critical clarifications and for pointing out any potential misrepresentation of their report [1]. We recognised in our review of the manuscript that 81% upon remote review were felt to be technically operable cases. However, in the end, only half were operated. In their response, R. Condliffe and co-workers provide further elaboration of their chronic thromboembolic pulmonary hypertension (CTEPH) case review process, in close partnership with the surgical centre at Papworth, including the important offer of an in-person consultation. So, were all 135 patients (72 who refused and 63 who were deemed unfit for surgery) examined and reviewed in person at the surgical reference centre? This is critical information left out in the original paper and in their correspondence, and the point which should be highlighted in this dialogue.
CTEPH operability assessment remains highly subjective and especially difficult to do remotely. These were key considerations why all major trials of medical therapy for inoperable CTEPH required an adjudication committee of experts [2–4]. However, even among experts there can be disagreements [5]. The adjudication committee from the CHEST-1 study noted that 22% of patients (69 of 312 cases) who were initially deemed inoperable by experts, either the central or designated adjudication committees, upon second review were changed to operable. So even in optimal circumstances with known experts, operability assessment is not infallible. In recognition, multiple CTEPH treatment algorithms have incorporated a recommendation to obtain a second opinion [6, 7]. In practice, we routinely witness cases deemed inoperable elsewhere or uncertain upon remote review that undergo successful pulmonary endarterectomy following local re-examination of the patient. Therefore, we commend the authors and their programmes for having the face-to-face consultation built into their routine practice.
However, if not all 135 patients were seen at Papworth before making an ultimate decision regarding surgery, it would help to know the details, and we encourage the authors to look at that data more carefully. If majority of the refusals declined an in-person evaluation at the reference centre, that data would be informative and potentially practice altering. If, on the other hand, many visited the reference centre and still refused surgery, what was the breakdown of refusal between the group that visited Papworth for evaluation and those who declined the visit? Is it possible that patients who refuse medical recommendations, such as visiting the reference centre to determine candidacy, are inherently higher risk long-term? But if all, or nearly all, of the 135 in fact were seen directly at the reference centre, that information may be of value to Papworth in their pursuit of treating as many technically operable cases as possible, as compelled by the data on the differences in survival. Finally, in recognition of the growing complexity of CTEPH treatment with expansion of numerous nonsurgical treatment modalities, along with the emphasis on the importance of pulmonary endarterectomy as spearheaded in this report, we recommend a message to all medical providers to refer CTEPH cases for comprehensive treatment evaluations at expert treatment centres, which are not only capable of investigating the nuances of each CTEPH case, but counsel patients effectively drawing from vast experience on the most appropriate therapy for that individual patient.
Footnotes
Conflict of interest: N.H. Kim has nothing to disclose.
Conflict of interest: E. Mayer has nothing to disclose.
- Received November 8, 2018.
- Accepted November 8, 2018.
- Copyright ©ERS 2019