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

The Prince Charles Hospital, Brisbane, Australia.
European Journal of Cardio-Thoracic Surgery (Impact Factor: 3.3). 03/2008; 33(2):157-63. DOI: 10.1016/j.ejcts.2007.11.009
Source: PubMed


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.
A retrospective review of all patients meeting the above criteria between July 2003 and June 2006. Selective antegrade cerebral perfusion at 20 degrees C was used as the initial means of reducing blood flow to the operative field.
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).
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.

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Available from: Alain Vuylsteke, Nov 25, 2014
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    • "Circulatory arrest is associated with cerebral and organ dysfunction secondary to the ischaemia during the circulatory arrest [3]. Selective cerebral perfusion has been utilized to reduce the cerebral complication rate, although the deleterious effects of the organs of the lower body remain [4]. "
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    ABSTRACT: Thromboendarterectomy remains a high-risk procedure. The use of circulatory arrest as a technique to allow pulmonary artery visualization is associated with cerebral and organ damage secondary to the ischaemic insult. Application of techniques learned from thoracic aortic stenting and minimal invasive valvular surgery may mean that circulatory arrest becomes an uncommon accompaniment to thromboendarterectomy.
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