Impact of prolonged waiting times for surgery during the COVID-19 pandemic on preoperative pulmonary hemodynamics and postoperative outcome of patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary endarterectomy

Abstract

Background: The COVID-19 pandemic challenged health care systems worldwide with its high mortality rate but also by limiting intensive care unit capacities leading to a critical delay in elective surgeries. Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and underdiagnosed disease often resulting in a delayed treatment. Life expectancy of patients with CTEPH is only 1 to 3 years when left untreated. Pulmonary endarterectomy (PEA) is the only curative treatment approach. (76) During the COVID- 19 pandemic PEA cases were postponed leading to an increased waiting time. The impact of a prolonged waiting time on preoperative pulmonary haemodynamics and outcome of patients after PEA has not been investigated. Methods: We conducted a retrospective single-center study at the Kerckhoff Clinic, Bad Nauheim. All patients with confirmed CTEPH diagnosis, that underwent a PEA surgery from March 1st 2018 till December 31st 2021 were included in the study and were divided in two groups: pandemic (P) and non-pandemic (NP). The main exposure variable was waiting time from onset of symptoms until PEA surgery. The primary endpoint was preoperative mean pulmonary artery pressure (mPAP) and pulmonary vascular resistance (PVR). Secondary endpoints included 30-day and 1-year mortality, length of ICU stay and prevalence of postoperative MACE and reperfusion pulmonary oedema (RPE). Results: A total of 436 patients were included into analysis (P: n=176; NP: n=260). Though mean waiting time from CTEPH diagnosis until PEA surgery was significantly longer in the pandemic group (P: 60±104 weeks vs. NP: 22±32 weeks, p<0.001), there was no difference in preoperative mPAP and PVR values between both groups. Waiting time was not associated with increased preoperative pulmonary haemodynamics. Short- (30-day-mortality P: 1.1% vs. NP: 1.5%, p = 0.721) and long-term outcome (1-year mortality P: 1.7% vs. NP 2.7%, p = 0.5) did not differ between both groups. There was no association between waiting time and occurrence of MACE or the length of ICU stay. An increased risk for development of RPE (OR 0.433, 95% CI: 0.226-0.827, p = 0.011) was detected. Conclusion: The COVID-19 pandemic led to an increased waiting time for PEA surgery in patients with CTEPH. While we did not show an impact on preoperative pulmonary haemodynamics, an increased risk for RPE – a severe complication after PEA surgery – was detected in our study cohort.