Thromboembolic pulmonary hypertension in the elderly: approach in a reference center for an increasing population

Abstract Background Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but serious and disabling disease that leads to right heart failure and early death if not treated appropriately. The management of this condition in the elderly is a challenge due to the multiple comorbidities, polypharmacy and adverse effects of procedures and drugs used for its treatment. This registry aimed to evaluate the comprehensive management and survival of a large cohort of elderly patients with CTEPH in a national and European reference center for PH. Methods This registry brings together 804 patients diagnosed with CTEPH evaluated by a multidisciplinary team in the PH Unit from 1996 to 2023. In this way, it is defined whether the patient is suitable for pulmonary endarterectomy (PE); pulmonary artery balloon angioplasty (BPA) or medical treatment (MT). Of the overall patient population, we identified 329 patients aged ≥65 years (40.9%) The characteristics of each treatment group, the clinical and hemodynamic results of each intervention, as well as long-term survival are described. A 10-year follow-up was performed Results Of these, 30.7% (101) underwent PE. BPA was started in 2013 and was performed in 100 (30.4%) patients, the rest received medical treatment with pulmonary vasodilator drugs (128 patients, 38.9%). In whole population, the mean age was 72.4±5.1 years (minimum age 65 years, maximum 87 years) and the female sex predominated (63.2%). Overall, 67.9% were in functional class III/IV; There was a 13.9% history of neoplasia, 25.7% of thrombophilia and 77.9% of pulmonary embolism. Comparatively, patients undergoing PE were significantly younger in relation to BPA and MT; 70±4 vs 72.9±5.2 vs 74.1±5.2 years respectively, p 0.0001, and in the surgical group the male sex predominated, unlike BPA and MT. There were no relevant differences between the three groups in relation to the distance in the six-minute walking test or NtproBNP value. The clinical and hemodynamic results of each of the treatments are shown in table 1. The hospital mortality was 6.9% and 2% for PE and BPA respectively. Survival rates for patients with CTEPH at 1, 3, and 5 years were 95.3%, 89%, and 84.8% for PE; 98.9%, 93.2%, and 91.2% for BPA; and 94%, 76.9%, and 72.9% for medical treatment, respectively. Long Rank p 0.002 (Figure 1) Conclusions In older adults with CTEPH, surgical and hemodynamic treatment improve functional capacity and hemodynamics, providing excellent long-term survival. Medical treatment should be reserved for cases non-candidates to interventional therapy. Discussion of the most appropriate treatment for each particular patient should be carried out by a multidisciplinary team.Table 1