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Yesterday I ran 30 minutes straight. 30 minutes! And I'm back to playing tennis! If you had told me just a few months ago I would have laughed. If I couldn't even climb a flight of stairs without running out of air." Satisfaction floods the voice of Antonio Sánchez, who finds it hard to believe his good fortune: "The life I thought was lost is once again a reality."
She has been returned by a complex intervention, a precision surgery that has cured the chronic thromboembolic pulmonary hypertension she suffered and that reduced her quality of life. He will never forget the date: on December 7, 2022, he says, he was born again. "Now I have two days to celebrate," says this 61-year-old Albacete, a biology teacher at a high school in Villarrobledo. "My sister congratulates me every 7th of every month. Without fail. Because that day changed everything."
That day the fatigue, shortness of breath or the need to take the elevator of the institute when the classroom was not on the ground floor were left behind. After three years of losing skills and giving up the sport, that day he won again. Behind this radical change is the Pulmonary Hypertension Unit of the 12 de Octubre University Hospital in Madrid, a national reference center for the approach of this type of disorder together with the Hospital Clínic de Barcelona. Sánchez arrived at that unit derived from the General Hospital of Albacete, whose Pneumology service was the first to detect that the pulmonary arteries of the Castilian-La Mancha were obstructed by thrombotic material, which caused serious pulmonary hypertension.
Thanks to the intervention, Antonio Sánchez has been able to play tennis again.
According to Pilar Escribano, head of the Multidisciplinary Unit of Pulmonary Hypertension on October 12, surgery is the treatment of choice for this type of pulmonary hypertension. It is a "potentially curative" approach, capable of resolving the disorder, but not everyone can do it. The intervention requires expert hands such as those of María Jesús López Gude, the surgeon who operated on Antonio Sánchez, among hundreds of other patients. The hospital is about to complete 400 cases of pulmonary thromboendarterectomy surgery, an intervention even more complex than its intricate name. In a large percentage of cases, this type of pulmonary hypertension occurs after an acute lung embolism. The clots caused by the vascular disorder do not dissolve, they remain inside the pulmonary arteries and, over time, become a fibrous material that obstructs the flow of the lungs.
A 'choreography' in the operating room
Removing this obstruction allows the problem to be solved, but that requires opening the patient's chest, using a heart-lung machine to make short, intermittent breaks in blood circulation and subjecting the patient to profound hypothermia (between 18ºC and 20ºC) to protect his body and, fundamentally, his brain. In addition to the technical requirements, the experience and skill of the professionals who carry out the operation is also essential. We proved it in an intervention of more than two hours in which a team of three surgeons, an anesthesiologist, two perfusionists, an instrumentalist and a nurse, led by López Gude, act with precision, perfectly coordinated and interpenetrated, almost as if they were performing a choreography. And the world witnesses the dance.
In the operating room, no one raises their voice, but each instruction is like a spring that everyone interprets to the millimeter. Paloma Orozco is the perfusionist who is responsible for stopping circulation. With a movement of yours, the blood stops flowing through the body, retained in the heart-lung machine. Each of these pauses lasts no more than 10 minutes in which Pedro Muñoz, the anesthesiologist, is aware with even more emphasis of all the parameters that show the patient's condition. Multiple figures, graphs and indicators reveal that everything is going well, despite the fact that the heart is not beating or blood flowing through the patient's vessels. "The intervention must be carried out in this way to be able to work inside the lung tree and remove the obstruction. If the blood were passing through the lung we could not see anything and we could not intervene, "explains López Gude, who has started with the right lung, in anartery that is barely 17 mm in diameter.
The material is very adherent, but the expertise of the surgeon -who thanks to the imaging tests to which the patient has undergone knows exactly where to use the tweezers and the scalpel-, manages to gradually extract the tree that is obstructed. In a tray, whitish, fibrous tissue accounts for the significant mass that was affecting the patient's pulmonary arteries.
In a high percentage of cases, the intervention provides complete cure of the disorder. "In our series, 19% are left with some pulmonary hypertension, but in many cases to a mild or moderate degree," says López Gude, who recalls that the intervention is not without risks. "Mortality, as in other experienced centers, is currently less than 5%."
"There was no room for fear"
When he was offered the possibility of going through the operating table, Antonio Sánchez did not hesitate for a moment. The alternative was not only a progressive loss of his already diminished quality of life, but also a very limited prognosis of life, so there was no room for fear: "I saw that the deterioration was being progressive. And I was told that the right half of the heart was already functioning inefficiently. And that the next step was for the liver and kidney problems to come..."
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Without treatment, the prognosis is disastrous, with a very high mortality within five years, "says Escribano, who calls for better monitoring of patients who have suffered an acute lung embolism to identify the cases most susceptible to suffering later chronic thromboembolic pulmonary hypertension, to be able to act early. Today, in Spain it is estimated that the prevalence of this problem is 8.4 cases per million inhabitants, figures that are below those of other countries in our environment. "Undoubtedly, this disease is underdiagnosed in Spain and more resources are needed to identify possible cases, because they are potentially curable," he stresses.
Although surgery is the treatment of choice, there are other procedures that can also be carried out when it is not possible to go through the operating room. This is the case of balloon angioplasty of pulmonary arteries, an approach that cardiologist María Teresa Velázquez performs at the Madrid center. "In those in which the problem is not operable or if residual hypertension has remained after the intervention, this technique can be performed, which allows dilating the obstructed vessels and also markedly improves functional capacity, decreases the severity of pulmonary hypertension and improves heart failure," explains the specialist. Up to 35% of patients with chronic thromboembolic pulmonary hypertension who arrive on October 12 undergo this technique, which has gained weight in recent years.
From left to right, doctors Velázquez, López Gude and Escribano.
"It is important to have a multidisciplinary team that allows us to evaluate which action is most appropriate in each case and which procedures allow a better solution for the patient," says Escribano.
Antonio, who has nothing but words of gratitude and admiration for the teams that attended him in Albacete and Madrid, remembers how his problem started, back in 2019. "I started to realize that I was losing physical capacity. I regularly participated in popular races and I noticed that people who I normally always beat were starting to arrive ahead of me. At first, I didn't give it any importance, but I immediately noticed that it was getting worse. I noticed that I was running less and less. I started not being able to last more than 10 minutes and there came a time when I could not stand even two. It was hard for me to get to the first floor at home. At the end of 2021 I had tests and the diagnosis came. First they tried a treatment with blood thinners, but nothing worked and it kept getting worse." At the end of 2022, Sánchez was admitted to the General Hospital of Albacete, from where he was transferred to October 12 and the surgery arrived. "I had surgery on December 7 and on December 17 I was able to return home," he recalls. "It had only been 10 days, but when I went up to the first floor I realized that I was better, that it did not cost me as much as before. From there, the improvement has been constant."
Throughout his life, this biology teacher has been a sports enthusiast. He went for a run at least two or three times a week and every weekend he played tennis with his friends. But what he experienced between 2019 and 2022 made him think that sports was a closed chapter of his life, something he could not enjoy again. That's why, when he was able to pick up the racket again, he couldn't contain his excitement. "Look, I'm almost happy to have muscle problems, because I thought it was something I wouldn't happen again," he says, amused. "A few days before I had surgery, I found out I was going to be a grandfather. If I had continued with the quality of life I had before, I would hardly have been able to hold my granddaughter in my arms." But his destiny changed. And Maya was born in mid-June, just in time to meet a grandfather who can now even take her on horseback.