Pulmonary Endarterectomy

Chronic thromboembolic pulmonary hypertension (CTEPH) is a condition whereby lung pressures are raised due to chronic blood clots in the lungs. Pulmonary endarterectomy (PEA) is potentially the curative treatment option for CTEPH. It is an open-heart surgery carried out to remove blood clots from the arteries in the lungs to help improve blood flow.

Pulmonary endarterectomy is a complex but potentially curative surgery for CTEPH. It involves placing the patient on a heart-lung bypass machine support that will take over the function of the heart and lungs as well as lowering the body temperature. This will allow the doctors time to carefully remove the clots from the lungs. The whole operation usually takes about seven to eight hours and is undertaken by a specially trained team of doctors and support staff.

Benefits

PEA surgery can cause significant improvement in symptoms of breathlessness and help bring pulmonary artery pressures back to normal. Patients with CTEPH who underwent PEA surgery generally reported improved quality of life.

Potential risks and complications

Common Risks

• Bleeding
• Reperfusion pulmonary edema
• Extended ICU stay
• Wound infection
• Irregular heart beat

Less Common Risks

• Subdural haematoma
• Renal and Heart failure
• Residual pulmonary hypertension

Rare Risks

• Death
• Stroke/brain injury
• Perforation of the pulmonary artery
  
  

Please follow the below instructions to prepare for your PEA surgery:

• Inform your doctor on your current medications as some medicines are unsuitable for consumption before a surgery. These include blood thinners, as well as traditional medications (which may contain blood thinners or steroids).
• If you are a smoker, please refrain from smoking during this time period.
• Provide your clinician with a list of your medical history, particularly for allergies.
• You may need to undergo other medical examinations prior to the surgery. Some examples of the tests include:
• ECG (electrocardiogram)
• Blood tests
• Chest x-ray
• Urine sample 
  
  

• Patients who have undergone a PEA surgery will be warded for a week or two or as long as they are needed for observation. An electrocardiogram (ECG) monitor will continuously record the rhythm of the heart in the first few days after the surgery.
• Physical therapy will slowly be introduced to strengthen the patient with light physical activities.
• Patients who have duly recovered their strength and have stable conditions will be arranged for discharge
• Follow-up appointments for regular check-ups will also be arranged at NHCS
  

Discharge advice

Pay attention to wound care

• Stitches will gradually disappear as the wound heals
• Use support pillow when coughing
• For female patients, it is advisable to wear a bra for 24hrs for six to 12 weeks after the surgery to provide support and allow the wound to heal
• Go to the nearest General Practitioner (GP) or polyclinic if there are wound discharges, redness, hot and tingly sensations or tenderness
  
  

Do not

• Apply scar ointment
• Lift heavy objects weighing more than 2kg
• Do heavy housework, such as vacuuming and mopping, for six weeks
• Do any pushing or pulling actions
• Cross your arms
• Drive for six to eight weeks

Watch out for complications

Seek medical consultation with your doctor at the Cardiac Clinics / Specialist Outpatient Clinic or at the Department of Emergency Medicine of Singapore General Hospital (after office hours), if any of the following conditions occurs:

• Fever
• Persistent headache
• Blurred vision, confusion, slurred speech, drooping eyelids or balancing problems
• Increasing breathlessness
• Fast, irregular heartbeats
• Worsening ankle or abdomen swelling
• Chest pain (different from wound pain)
• Feeling cold and clammy or sweaty

Medication

Anticoagulation

Anticoagulations are blood-thinning medications that help prevent blood from clotting. Patients who are on anticoagulations need to take them for long-term or in most cases, for the rest of their life.

Blood-thinning medications

• Warfarin: International Normalised Ratio (INR), a form of blood test, targets to be within 2-3
• Other drugs which do not require INR check: Rivaroxaban, Apixaban or Darbigartran
  

Diuretics

Some patients may require this medication to remove excess water from the body.

Side effects of the medication

• Frequent urination
• Low blood pressure
• Dehydration
• Nausea and vomiting
• Low potassium / sodium level cause arrhythmias
• Muscle cramps
• Dizziness

Oxygen Therapy

Some patients may require oxygen therapy after discharge to help them breathe better and improve their quality of life.

Pulmonary Vasodilatators

Some patients may require specific drugs to lower the blood pressure in the lungs. These are only given to those who have persistent pulmonary hypertension after the surgery.

Lifestyle

• Nutrition: A balanced diet is important to promote healing.
• Exercise: It is recommended to resume daily activities.
• Showering: Shower daily with back facing the shower head to prevent water spraying directly on the wound. Take note to keep surgical wound clean and dry.
• Housework: Light housework is tolerable.
• Driving: It is advisable to only resume driving in six to eight weeks’ time, after the surgery. Do place cushion on chest for better comfort.