A 70-year-old woman with a history of proven recurrent pulmonary emboli but no other comorbidities presents with breathlessness over a number of months. She is in NYHA class III. Her INR has been within the therapeutic range. Serial echocardiograms demonstrate persistent features of pulmonary hypertension.
Which one of the following is the most important measure?a. Persist with warfarin; the clot will resolve eventually
This description fits with a diagnosis of chronic thromboembolic PH (CTEPH). In those patients with CTEPH in whom anticoagulation at therapeutic levels has proved ineffective at bringing down pulmonary pressures, consideration should be given to surgery with pulmonary end-arterectomy. This procedure can be curative in carefully selected patients. Advanced therapies can be considered if the patient is felt to be inoperable. Balloon atrial septostomy, which permits the right heart to vent into the left atrium, is used infrequently in selected patients with refractory syncope and heart failure.