Inside the Surgical Suite: Meeting the Challenges of CTEPH

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It is so rare to find a curable cause of pulmonary arterial hypertension (PAH). In preparing the topics to be covered for this issue we decided that surgically curable PAH is one of the most challenging situations we face, particularly in terms of appropriate selection of patients and in our preoperative preparation. One of the major challenges confronting us is bringing the right patient into the operating room suite and addressing all of the issues impinging on our decision to perform surgery as we determine whether the chronic thromboembolic pulmonary hypertension (CTEPH) is surgically accessible and to what extent we can make a correlation between angiographic and hemodynamic findings. This is one of the critical issues we addressed in our Roundtable Discussion as we touched on a broad range of topics related to thromboendarterectomy to bring you the latest thinking from preeminent experts in the United States and abroad.

As we consulted these experts, we turned to the University of California, San Diego, because this center is so widely recognized as the world's leading referral center for pulmonary thromboendarterectomy surgery. Beginning with the pioneering work of Ken Moser, MD, UCSD has contributed enormously to developing guidelines for the evaluation of patients to determine their surgical candidacy and for performance of the procedure itself. Continuing the theme of this issue, two articles written by UCSD investigators provide an in-depth analysis of preoperative and operative considerations. The first begins with the subtle and nonspecific symptoms that may provide the first clues of CTEPH and offers important insights on confirmatory catheterization studies. The second article is an insider's view of thromboendarterectomy, information that anyone would want to retain as an essential reference for one's files.

The wealth of information presented here highlights how far we have come in the evolution of our thinking about thromboembolic disease in the setting of PAH. We have made dramatic strides, moving away from the earlier and simplistic view of its being merely a mechanical obstruction of the major pulmonary arteries. The experience at major centers has redefined our approach and given us important new tools with which to achieve that rare cure in many patients with this disease.