Abstract
CTEPH patients over 80 years old undergoing pulmonary endarterectomy have similar outcomes to those under 80 years http://ow.ly/MlCj30guFPu
To the Editor:
Pulmonary endarterectomy (PEA) is the treatment of choice in operable chronic thromboembolic pulmonary hypertension (CTEPH) with excellent long-term outcomes [1]. It is a complex surgical procedure requiring cardiopulmonary bypass and removal of obstructive thromboembolic material during periods of deep hypothermic circulatory arrest [1]. We have observed an increase in the number of older CTEPH patients referred for consideration of PEA, which is consistent with other cardiothoracic surgeries. The UK population is ageing with a projected 3% increase in subjects aged >85 years in the next 20 years [2]. This may be mirrored by patients with CTEPH getting older, as the incidence of pulmonary embolism, which frequently precedes CTEPH, markedly increases with age [3, 4]. Furthermore, an epidemiological analysis by Gall et al. [5] has projected that the annual incidence of CTEPH will increase over the next 10 years. Therefore, the management of CTEPH in older patients is a pertinent topic for investigation.
We previously reported that hospital survival in patients over 70 years undergoing PEA was similar to those under 70 years, albeit with longer hospital and intensive care unit (ICU) stays [6]. For selected cardiac surgeries (coronary artery bypass and aortic valve surgery), octogenarians have equivalent or improved long-term mortality than an age- and sex-matched population [7, 8]. Furthermore, patient reported outcomes (PROs) including quality of life improve postoperatively, and are equivalent or better than a matched general population of octogenarians [7, 9]. However, increased in-hospital mortality and prolonged hospital/ICU length of stay have also been reported, which may translate to increased health utilisation costs [10, 11]. Therefore, in the current study, we aimed to assess the outcomes of CTEPH patients over 80 years old who underwent PEA.
Consecutive CTEPH patients undergoing PEA from June 2006 to August 2016 at the UK National PEA centre (Papworth, UK) were included in a retrospective analysis. The diagnosis of CTEPH was based on international criteria [12]. Suitability for PEA was discussed by a multidisciplinary team, comprising pulmonary hypertension physicians, specialist cardiothoracic radiologists and pulmonary endarterectomy surgeons. The cohort was dichotomised into those over and under 80 years according to age at the time of surgery. Preoperative baseline and postoperative 3–6-month follow-up data were recorded, with follow-up data included until 3 months after the end of the census period. PROs were assessed using the Cambridge Pulmonary Hypertension Outcome Review (CAMPHOR) score, a PH-specific quality of life measure [13]. Groups were compared using a Chi-squared test for categorical data, Wilcoxon rank-sum test for continuous data and log-rank test for survival data. A false discovery rate adjusted p-value was used to account for multiple testing.
A total of 1152 individuals underwent PEA (under 80 years, 1115 (97%); over 80, 37 (3%)) during the study period. Baseline and 3–6-month follow-up variables and outcomes are summarised in table 1. Overall survival at 1, 3 and 5 years was 91.8%, 88.2% and 84.4% in the under 80 group, and 83.5%, 76.4% and 69.4% in the over 80 group. Although survival was lower in the over 80 group (log-rank test; p=0.020), it was no different from an age- and sex-matched UK reference population (p=0.500) [15].
There were significant improvements in World Health Organization (WHO) functional class, 6-minute walk distance (6MWD) and haemodynamics for both the under and the over 80s post-PEA. Although the 6MWD was lower in the over 80s post-PEA (286±164 versus 360±92; p=0.020) there was an equivalent change from baseline (p=0.676) reflecting the same magnitude of improvement. Furthermore, there was no difference in the median change from baseline for WHO functional class, haemodynamics or PROs between the under and the over 80s, indicating an equivalent improvement in outcomes.
There were more concomitant cardiac surgical procedures in the over 80 group (11% versus 27%; p=0.042), predominantly due to more coronary artery bypass grafts (7% versus 19%). There was a shorter cardiopulmonary bypass time (323±305 min versus 305±65; p=0.020) in the over 80s but no difference in the total deep hypothermic circulatory arrest time or type of surgical disease (Jamieson classification based on location and morphology) (p=0.230 and p=1.000). The hospital length of stay was longer in those over 80 (19±7 versus 14±10 days; p=0.020) but there was no difference in time spent on the ICU (4±3 versus 5±5 days; p=0.310). There was also no difference in post-PEA complications (p=1.000) or in hospital mortality (4% versus 8%; p=0.510).
Despite the study limitations (small group size of over 80s, retrospective single-centre analysis), we found similar outcomes in patients under and over 80 years old undergoing PEA, except for a prolonged hospital length of stay in octogenarians. Although survival is reduced in the over 80 group compared with the under 80s, it is no different to a reference age- and sex-matched UK population. The greater number of concomitant cardiac surgeries in octogenarians could indicate that their improvement is multifactorial. Future research should consider the health utilisation and cost implications of older patients undergoing PEA, given they have a prolonged hospital length of stay.
We acknowledge that CTEPH patients over 80 years were highly selected to undergo PEA and therefore our results may not apply to ‘all comers’. However, it reinforces the effectiveness of the PEA selection process at expert centres. Age alone should not be a contraindication for PEA, and individuals with suspected CTEPH should be referred for specialist evaluation.
Disclosures
Supplementary Material
J. Cannon ERJ-01804-2017_Cannon
D. Jenkins ERJ-01804-2017_Jenkins
M. Newnham ERJ-01804-2017_Newnham
J. Pepke-Zaba ERJ-01804-2017_Pepke-Zaba
K. Sheares ERJ-01804-2017_Sheares
D. Taboada ERJ-01804-2017_Taboada
Acknowledgements
The authors wish to thank the National Pulmonary Hypertension Centres UK and Ireland for referring the patients that were considered for PEA.
Footnotes
Conflict of interest: Disclosures can be found alongside this article at erj.ersjournals.com
- Received September 2, 2017.
- Accepted September 16, 2017.
- Copyright ©ERS 2017