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Pulmonary endarterectomy is possible and effective without the use of complete circulatory arrest—the UK experience in over 150 patients

^a Papworth Hospital, Cambridge CB23 3RE, United Kingdom
^b The Prince Charles Hospital, Brisbane, Australia
^c James Cook University Hospital, Middlesborough, United Kingdom

Received 23 October 2006; received in revised form 16 October 2007; accepted 2 November 2007.

^_* Corresponding author. Tel.: +44 1480 830541/364806; fax: +44 1480 364709. (Email: david.jenkins{at}papworth.nhs.uk).

Objective: Pulmonary endarterectomy is the best treatment for patients with chronic thromboembolic pulmonary hypertension. Traditionally pulmonary endarterectomy has been performed utilising deep hypothermic circulatory arrest to provide a bloodless field, but some recent reports have challenged this concept. We reviewed our experience with selective antegrade cerebral perfusion as the initial strategy of controlling bronchial collateral flow to avoid complete circulatory arrest in patients undergoing pulmonary endarterectomy. Methods: A retrospective review of all patients meeting the above criteria between July 2003 and June 2006. Selective antegrade cerebral perfusion at 20 °C was used as the initial means of reducing blood flow to the operative field. Results: One hundred and fifty-one patients (83 male, 68 female, mean age 56 ± 16 years) were operated on using this strategy. The preoperative New York Heart Association class distribution showed the majority to be in class III or IV (142 of 151). At initial assessment, mean pulmonary artery pressure was 49 ± 12 mmHg and mean pulmonary vascular resistance was 851 ± 391 dynes s cm^–5. Selective antegrade cerebral perfusion was required in 145 for a total period of 63 ± 24 min. Thirteen (9%) patients required conversion to deep hypothermic arrest for completion of the operation. In-hospital mortality was 22 (15%). There were no instances of focal neurological deficit. Prearranged clinical follow-up for 3 and 12 months was 97% complete with one late death by 3 months and one more by 12 months. The majority were in New York Heart Association class I or II at 3 months (102 of 115) and 12 months (65 of 74). At 3-month follow-up the mean pulmonary artery pressure was 27 ± 10 mmHg and pulmonary vascular resistance was 304 ± 220 dynes s cm^–5. Conclusions: Overall results improved with era and institutional experience. The use of selective antegrade cerebral perfusion for pulmonary endarterectomy appears to be technically feasible in the majority of patients and is an alternative to complete circulatory arrest. To clarify its role further, comparison with deep hypothermic circulatory arrest in a randomised controlled trial is necessary.

Key Words: Pulmonary endarterectomy • Pulmonary thromboendarterectomy • Selective antegrade cerebral perfusion • Deep hypothermic circulatory arrest • Pulmonary hypertension