What is Pulmonary Thromboendarterectomy (PTE)?

Podcast Transcript

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Nicholas Smedira, MD, MBA: Hi, I'm Nick Smedira. I'm one of the cardiac surgeons at the Cleveland Clinic. And my colleague...

Haytham Elgharably, MD: Yeah, I'm Haytham Elgharably. I'm one of the heart surgeons here at the Cleveland Clinic too.

Nicholas Smedira, MD, MBA: And we and the center at the Clinic had a long interest in treating patients who have had pulmonary embolisms, and the lingo's a little bit confusing. You hear things like CTEPH, which is the chronic form of the disease, and PTE, which is pulmonary thromboendarterectomy. And we're going to describe what these procedures are and try to simplify the understanding. I think one of the key things about our organization is we have a multidisciplinary team that evaluates our patients with a history of pulmonary embolism, because there's a lot of disorders that can mimic pulmonary embolism symptoms. And then through that evaluation with imaging, we decide what's the best form of therapy because now there's drugs, there's interventions and there's the surgical therapy. So Haytham, tell us a little bit how we go through the process of assessing patients.

Haytham Elgharably, MD: So these patients usually present first to the pulmonologist and then once they feel that they have the diagnosis that we need to discuss in the multidisciplinary team, we have a committee meeting every week now, a day a week. And then we go through these cases with the pulmonologist, the interventional radiologist, and we have two surgeon doing these cases now. And we also have a person from Vascular Medicine. And we take these cases on individual basis because each patient's different from the other one. The pathology is different. The pressure in the lung is different. And then as you stated, there is either drug therapy or catheter based therapy or surgery. So between the committee, we go through the images, the number, the pressure in the lungs, and then decide which therapy is best for that patient.

Nicholas Smedira, MD, MBA: So the patient would go through some testing, which would include CT scanning, a pulmonary angiogram, usually pulmonary function studies, the breathing, any other tests?

Haytham Elgharably, MD: Cardiac cath too.

Nicholas Smedira, MD, MBA: Cardiac cath. Echocardiograms.

Haytham Elgharably, MD: Echo.

Nicholas Smedira, MD, MBA: So there's quite a bit of testing that goes on. So as you suggest, we're really trying to identify what's the cause of these symptoms and what's generating the pulmonary hypertension.

Haytham Elgharably, MD: Yes. And sometime patient had clots in their legs before.

Nicholas Smedira, MD, MBA: That's right.

Haytham Elgharably, MD: And they travel to the lung. Some people had hypocoagular state so that's why we have a vascular medicine doctor on that committee.

Nicholas Smedira, MD, MBA: So it really requires a multidisciplinary team to think through all the nuances of it.

Haytham Elgharably, MD: Yeah.

Nicholas Smedira, MD, MBA: I always thought this operation was one of the more technically challenging operations that we do.

Haytham Elgharably, MD: Yes.

Nicholas Smedira, MD, MBA: Do you agree?

Haytham Elgharably, MD: Yeah, it's very tedious.

Nicholas Smedira, MD, MBA: And tell me a little bit about the procedure and why it's unique to a lot of what we do in cardiac surgery.

Haytham Elgharably, MD: Yeah. So this is a standard thoracic sternotomy. We have to open the full sternotomy incision. We have to put the patient heart lung machine and then cool the body down, because the main principle of the operation that we opened the vessel going to each lung and try to find the scar in the wall of these vessel and strip it out and track it down in the smaller vessel as far as we could see, or can reach. And that's very technically challenging and really tedious work on each side. And we use a heart lung machine to cool the body of the patient down to lower the flow on the pump. So we have less blood in the field.

Nicholas Smedira, MD, MBA: Yeah. That's one of the key elements. And we use centigrade, but I memorized what it meant. So it's cooling the body down to about 60 degrees from standard temperature with the idea that'll protect the brain and the organs as we limit the amount of blood in our field. How's our results with this operation?

Haytham Elgharably, MD: The result has been pretty successful so far because we have this multidisciplinary team. So we really pick up the good candidates for this operation that we're comfortable we're going to take most of the disease out as far as possible. Because the idea in our operation, that we go through the smaller vessel, like in the periphery on the lung, to lower the pressure and the lung. So that's why we go through the committee with the images, with the radiologist, to make sure that this is someone we're going to take and get good results with. So it has been pretty successful.

Nicholas Smedira, MD, MBA: Yeah. That's been my experience. With the advances in the heart lung machine mechanics, the advances with preoperative preparation that the pulmonologists are so helpful with, with the drugs, that we now have for pulmonary hypertension, the anesthesia management, the blood coagulation management with our vascular medicine colleagues, the results are quite good. And in my experience, in some patients, the pulmonary pressures come to normal right away.

Haytham Elgharably, MD: Right away.           

Nicholas Smedira, MD, MBA: But in some patients they drop maybe 50%. And then over time we see a gradual reduction to close to normal. Is that ...

Haytham Elgharably, MD: That's correct. Yes. Sometimes if we get pretty good success in the surgery it drop right away to almost normal. Sometimes we come down around 50%. And then we evaluate this patient again with pulmonologist after surgery. And everyone's going to be on a blood thinner obviously, but sometimes we add another drug therapy to lower the blood pressure for the next few months, until they come back to almost normal.

Nicholas Smedira, MD, MBA: Recovery. Length of stay's a little bit longer than average surgery because the ICU stay may be a couple days long. What would you tell the patient that the hospital course would look like?

Haytham Elgharably, MD: I usually tell them, yes, at least couple days in ICU. Usually the first day, our protocol now to keep the patient on the mechanical ventilation the first night. Just easier to control the pressure on the lung and the heart pumping function. And then we take the breathing tube out the next day. They stay another day in ICU to look at their numbers and pressures in the lung and the heart. And then they go to the regular floor, maybe for five to seven days, based on the blood thinner therapy that we're going to use. And if we need to reach a certain level before you go home. Also, usually we're able to wean their oxygen, if they were on oxygen before surgery down to no oxygen before they leave. So takes some time. Longer than standard cardiac surgery.

Nicholas Smedira, MD, MBA: My experience has been that if we get the pulmonary pressures back to normal, then the expectation is that they'll have a normal life expectancy.

Haytham Elgharably, MD: Yeah, that's correct. Yeah. So as you said before, as we said, sometimes they have no symptoms right away. They come off the oxygen right away. Sometimes it takes few weeks. But yeah, the expectation that by three to six months, they're back to normal daily life activities.

Nicholas Smedira, MD, MBA: One of the real interesting advances has been in sort of translating what we've done with coronary artery disease with plaques and balloons and blowing them up and using them in the lung arteries for the obstruction that's too far for us to reach. We can't surgically get there. How have we been doing with the angioplasty approach?

Haytham Elgharably, MD: Yeah. So that also has been evolving pretty good. Now they have smaller catheter that can go further out in the smaller vessels. And this is also part of the discussion, I know, with some of the patient that we think we can, if they're young enough, they have a lot of bulky disease in their artery, we try to go surgery first. And if they have residual blockages, one of the distal vessel, then we can get the interventional radiologists to go back, and after this small vessel, and open it with the catheter.

Nicholas Smedira, MD, MBA: I think that's been a major advance because there's, I think, a fair number of patients where that there is distal disease where we simply can't reach. It's just too far, or too difficult to get the instruments in down in there, and to be able to have an adjunct therapy that can then sort of take over after what we've done if there's residual disease, I think it's been a fantastic advance in that. Any advice for families, if they're ...

Haytham Elgharably, MD: Sorry. I think these kind of surgeries, as you said, it's very technically challenge and tedious to do, so these surgeries should be done only in center of excellence that they're used to these surgeries and they have this multidisciplinary forum that they can go through the cases on an individual basis and then provide the best therapy tailored to the patient.

Nicholas Smedira, MD, MBA: Yeah. I would strongly echo that. It is a challenging operation. And to the credit of the group in San Diego, they've developed a lot of the protocols for the management in the operating room. I learned from them and brought that their techniques and drug therapies here. And then, with Dr. Gustavo Heresi from Pulmonary Medicine, we really refined how we evaluate and treat patients. So it's been a great collaborative effort. I think have made it an extremely safe operation and a reliable operation.

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