• Andrea M D'Armini, Marco Morsolini, Gabriella Mattiucci, Valentina Grazioli, Maurizio Pin, Adele Valentini, Giuseppe Silvaggio, Catherine Klersy, and Roberto Dore.
• Department of Clinical-Surgical, Diagnostic and Pediatric Sciences, University of Pavia School of Medicine, Pavia, Italy; Cardiac Surgery, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy. Electronic address: darmini@smatteo.pv.it.
• J. Thorac. Cardiovasc. Surg.. 2014 Sep 1;148(3):1005-11; 1012.e1-2; discussion 1011-2.

ObjectivesChronic thromboembolic pulmonary hypertension can be cured by pulmonary endarterectomy. Operability assessment remains a major concern, because there are no well-defined criteria to discriminate proximal from distal obstructions, and surgical candidacy depends mostly on the surgeon's experience. The intraoperative classification of chronic thromboembolic pulmonary hypertension describes 4 types of lesions, based on anatomy and location. We describe our recent experience with the more distal (type 3) disease.MethodsMore than 500 pulmonary endarterectomies were performed at Foundation I.R.C.C.S. Policlinico San Matteo (Pavia, Italy). Because of recent changes in the patient population, 331 endarterectomies performed from January 2008 to December 2013 were analyzed. Two groups of patients were identified according to the intraoperative classification: proximal (type 1 and type 2 lesions, 221 patients) and distal (type 3 lesions, 110 patients).ResultsThe number of endarterectomies for distal chronic thromboembolic pulmonary hypertension increased significantly over time (currently ∼37%). Deep venous thrombosis was confirmed as a risk factor for proximal disease, whereas patients with distal obstruction had a higher prevalence of indwelling intravascular devices. Overall hospital mortality was 6.9%, with no difference in the 2 groups. Postoperative survival was excellent. In all patients, surgery was followed by a significant and sustained improvement in hemodynamic, echocardiographic, and functional parameters, with no difference between proximal and distal cases.ConclusionsAlthough distal chronic thromboembolic pulmonary hypertension represents the most challenging situation, the postoperative outcomes of both proximal and distal cases are excellent. The diagnosis of inoperable chronic thromboembolic pulmonary hypertension should be achieved only in experienced centers, because many patients who have been deemed inoperable might benefit from favorable surgical outcomes.Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

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