CHEST How I Do It: Management of chronic thromboembolic pulmonary hypertension before and after pulmonary thromboendarterectomy

Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension characterized by unresolved thromboemboli and subsequent fibrotic obstructions of the pulmonary arteries. Pulmonary thromboendarterectomy (PTE) is the treatment of choice if feasible. Multidisciplinary evaluation by an experienced CTEPH team is essential to ensure proper patient selection, operability assessment, and appropriate perioperative management of patients with high-risk hemodynamics and right ventricular failure. In the early postoperative period, close monitoring in the intensive care unit (ICU) is necessary. These patients are at risk for profound oxygenation and hemodynamic derangements following PTE surgery. Inotropic support, diuresis, mechanical ventilation with adequately large tidal volumes, and supportive care for potential complications such as reperfusion lung injury or airway hemorrhage, are at the core of ICU management. Anticoagulation is a key cornerstone of CTEPH treatment and must be started as soon as possible, while carefully weighing the risks of bleeding complications versus rethrombosis. Follow-up evaluation after pulmonary endarterectomy is essential to evaluate for residual pulmonary hypertension and identify patients who may benefit from additional treatments. Ultimately, optimal outcomes depend on an experienced multidisciplinary CTEPH team with an approach to care that spans the preoperative, early postoperative, and post-discharge phases. This review aims to provide clinicians with practical guidance for the perioperative management of CTEPH patients undergoing PTE surgery.