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Eur J Cardiothorac Surg 2006;30:563-565
© 2006 Elsevier Science NL

How-to-do-it

Pulmonary endarterectomy: is there an alternative to profound hypothermia with cardiocirculatory arrest?

Piero Maria Mikusa, Andrea Dell’Amorea,*, Saverio Pastoreb, Nazzareno Galièc

a Heart and Lung Transplantation Program, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti n.9, Bologna, Italy
b Department of Cardiac Surgery Anaesthesiology, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti n.9, Bologna, Italy
c Department of Cardiology, S.Orsola-Malpighi Hospital, University of Bologna, Via Massarenti n.9, Bologna, Italy

Received 28 October 2005; received in revised form 6 June 2006; accepted 26 June 2006.

* Corresponding author. Address: Via Battuti Verdi n.1, PC:47100 Forlì, Italy. Tel.: +39 03356223366; fax: +39 0516364751. (Email: dellamore76{at}libero.it).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Discussion
 References
 
The current surgical strategy for pulmonary endarterectomy (PEA) involves the use of extracorporeal circulation and hypothermic circulatory arrest (HCA). The aim of the present study was to test the feasibility of a different strategy of extracorporeal circulation, which could prevent bronchial back bleeding and allow a bloodless operating field, avoiding the risks associated with HCA in patients undergoing pulmonary endarterectomy. Between June 2004 and September 2005, eight patients underwent PEA without HCA. We introduced a double venting of the left heart sections, utilizing two cannulas placed in the left ventricle and atrium. Both vent cannulas are connected with vacuum device to prevent back-bleeding and left heart distension from the large amount of bronchial flow. We were able to perform pulmonary endarterectomy avoiding circulatory arrest and deep hypothermia without sacrificing the effectiveness of the procedure. The initial encouraging results have convinced us to apply systematically this technique in the cases operated in our center, even though further investigations are necessary to fully examine this technique.

Key Words: Great vessels disease • Cardiopulmonary bypass (CPB) • Endarterectomy • Pulmonary arteries • Pulmonary embolism


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Discussion
 References
 
The current surgical strategy for pulmonary endarterectomy (PEA) has evolved over the past 10 years and nowadays is the therapy of choice for chronic thromboembolic pulmonary hypertension [1].

The surgical technique involves cardiopulmonary bypass (CPB), deep hypothermia and intermittent periods of hypothermic circulatory arrest (HCA) to minimize the continuous retrograde blood flow obscuring the operative field due to bronchial arteries hyperplasia [2].

To reduce the sequelae of HCA, we developed a different strategy of CPB avoiding HCA as well bronchial back-bleeding and we present our preliminary results.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Discussion
 References
 
Between June 2004 and September 2005, eight patients underwent PEA without HCA.

Preoperatively, all patients were in New York Heart Association (NYHA) functional class III (n = 4) or IV (n = 4), the mean age was 43.8 years (M/F; 3/5). All patients had type II pulmonary occlusive disease [3].

After median sternotomy and systemic heparinization (3 mg/kg), CPB is established via ascending aorta and both caval veins. Main pulmonary artery vent is placed 1 cm distal to pulmonary valve. In addition to bicaval, aortic and pulmonary-trunk cannulations, we introduced an alternative venting of the left heart sections. Two 18-Fr Terumo-4334 cannulas were placed in the left ventricle and left atrium. The cannulas are connected to a reservoir (Dideco BT 844) inside which negative pressure is created by Baxter vacuum device equipped with Boehringer Suction Regulator (model-7720) which allows 0–100 mmHg vacuum modulation range. The collected blood is transferred in the cardiotomy reservoir by a roller pump (Fig. 1 ).


Figure 1
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  		Fig. 1. Schematic view of extracorporeal circulation system with modified left heart venting lines. 1: left vent from the left ventricle, 2: left vent from the left atrium. Both vent lines are connected with Dideco BT 844 Reservoir and the vacuum device (IVC: inferior vena cava; SVC: superior vena cava).

 
The CPB pump flow has been adjusted on the basis of patient's temperature and mixed venous oxygen saturation (>65%), continuously assessed by a DataMaster-7572 Dideco-saturimeter. Cooling is started to reach a core temperature of 26 °C. 18-Fr Terumo-4334 cannula is introduced through the right upper pulmonary vein into left ventricle. Aorta is cross-clamped and cold-crystalloid cardioplegia (Custodiol® Koehler-Chemie, Alsbach-Haenlein, Germany) is administered in the aortic root. An additional vent is placed in the left atrium through left upper pulmonary vein. Both vent cannulas are connected with vacuum device. During PEA we modulated the negative pressure by the Suction-Regulator, usually in our experience 30 mmHg was enough. At the same time, patient's postural changes are used to place the left atrium in lowest recumbent position. Both expedients allowed us to obtain a bloodless operative field minimizing back-bleeding.

The surgical procedure was performed as previously described [3].

When the endarterectomy is complete, we start deairing and rewarming, than both left vents are removed.

Before CPB is stopped, 40–60 min of myocardial and lungs reperfusion with low pulmonary pressure (10–15 mmHg) is used to avoid reperfusion injuries, then all cannulas are removed and protamine (3 mg/kg) is given.


   3. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Discussion
References
 
Pulmonary endarterectomy has always been recognized as a difficult procedure often burdened by a high mortality. However, introduction of HCA into the technique in the 1990s resulted in the widespread diffusion of the procedure.

The surgical technique has also been improved by the use of specific instruments and nowadays the surgical mortality rate ranging from 4.4% to 24% [2].

However, the reported experience tends to focus more on mortality rather than on postoperative morbidity. In 1997 Parquin et al. reported less than 5% incidence of bleedings and 3% of serious neurological complications. The same group observed a significant number of postoperative delirium, which, in the authors’ opinion, could be correlated to circulatory arrest [4].

Recently, HCA for PEA has median duration of 36 ± 11 min [2], which, even when it is interrupted for short period of reperfusion, may be the cause of postoperative complications linked to metabolic changes involved with this technique [5].

To minimize the sequelae of HCA, different groups reported in literature some technical advances, introducing the use of antegrade cerebral perfusion and moderate hypothermia with good results [6,7].

Our approach minimizes bronchial back-bleeding during endarterectomy applying hydrostatic and negative pression to the left sections of the heart. Hypothermia is stopped at 26 °C; in these conditions we have been able to perform the procedure completely without HCA and prolonged rewarming phases. The visibility of the operatory field was not compromised.

As expected, there was a significant postoperative improvement of patients’ hemodynamics (Table 1 ).


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  		Table 1. Comparison between pre- and postoperative hemodynamic data
 
There were neither in-hospital deaths nor any major intraoperative complications.

Moreover, avoiding HCA none of eight patients had major lung reperfusion injuries, postoperative delirium, neurological deficits, renal failure and coagulative disorders. No rethoracotomy was necessary for bleeding.

Compared to others alternative approach [6,7] we feel that ours is easier to perform and allow us to obtain a bloodless operative field, particularly in case of type I–II disease.

Furthermore, in very distal obstruction when the visibility is poor, we can lower the core temperature and perform HCA as in the standard technique.

The only significant difference in our approach is a simple modification in the CPB circuits and that for us the circulatory arrest is not considered mandatory.

The initial encouraging results have convinced us to apply systematically this technique, even though further investigations are necessary to fully examine this technique. We believe that the introduction of an alternative strategy without HCA could furthermore reduce the morbidity and mortality of this complex operation.

Afterwards PEA on HCA remains the technique of choice, on the evidence of very good results reported in literature from groups with extensive experience in this field.


   Acknowledgments
 
We would like to thank: professor Walter Klepetko (Wien – Austria) for his suggestion and availability; professor Giorgio Arpesella, chief of heart and lung transplantation program, S.Orsola-Malpighi Hospital, University of Bologna; and Erika De Toni Perfusion technician, Cardiac Surgery Department, S.Orsola-Malpighi Hospital, University of Bologna for their collaboration.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Discussion
 References
 

  1. Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med 2001;345:1465-1472.[Free Full Text]
  2. Jamienson SW, Kapelanski DP, Sakakibara N, Manecke GR, Thiestlethwa PA, Kerr KM, Channik RN, Fedullo PF, Auger WR. Pulmonary endoarteriectomy: experience and lesson learned in 1500 cases. Ann Thorac Surg 2003;76(5):1457-1462.[Abstract/Free Full Text]
  3. Jamieson SW. Pulmonary thromboendoarterectomy. In: Franco KL, Putman JB, editors. Advanced therapy in thoracic surgery. Hamilton, Ontario: BC Decker; 1998. pp. 310.
  4. Parquin F, Auriant I, Jallot A, Fournier JL, Lescot B. Complications apres endoarteriectomie pulmonaire et principe de la reanimation. Atti Journèe de patholgie thoracique 2002. 22 Mars 2002 Centre Chirurgicale Marie Lannelongue Paris..
  5. Cooper WA, Duarte IG, Thourani VH, Nakamura M, Wang NP, Brown III WN, Gott JP, Vinten-Johansen J, Guyton RA. Hypothermic circulatory arrest causes multisystem vascular endothelial dysfunction and apoptosis. Ann Thorac Surg 2000;69:696-702.[Abstract/Free Full Text]
  6. Hagl C, Khaladj N, Peters T, Hoeper MM, Logemann F, Haverich A, Macchiarini P. Technical advances of pulmonary thromboendoarterectomy for chronic thromboembolic pulmonary hypertension. Eur J Cardiothorac Surg 2003;23:776-781.[Abstract/Free Full Text]
  7. Masuda M, Mogi K, Nakaya M, Pearce Y, Imamaki M, Shimura H, Okada Y, Nishimura K, Nakajima N. Surgical treatment for chronic pulmonary thromboembolism under cardiopulmonary bypass with selective cerebral perfusion. Surg Today 2001;31:108-112.[CrossRef][Medline]



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Related Collections
Right arrow Cardiac - physiology
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Right arrow Great vessels

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