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: 2.67). 03/2008; 33(2):157-63. DOI: 10.1016/j.ejcts.2007.11.009
Source: PubMed

ABSTRACT 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.

  • Anesthesiology 03/2014; · 5.16 Impact Factor
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    ABSTRACT: Pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) remains challenging with some difficulties, although it has been a well-established procedure. Its current situation including indications, surgical techniques with perioperative management, early and late outcome, and risk factors for mortality and poor hemodynamic improvement are reviewed. With the recent advancement of PEA including perioperative management and the accumulation of experiences, early outcome has been improved with low mortality rates, which are 5-10 % in most or <5 % in experienced centers. The risk factors for mortality were high pulmonary vascular resistance before and immediately after surgery, poor preoperative exercise capacity (NYHA-class IV), and advanced age. Reperfusion lung injury and residual pulmonary hypertension remain problematic as the most serious complications. The latter occurs in cases with surgically inaccessible distal lesions. For them, more careful perioperative management using pharmacological agents in conjunction with skillful PEA is required, occasionally with prompt use of percutaneous cardiopulmonary support. Although there have been a few reports on the long-term outcome, it is also favorable with good survival and event-free rates, which are affected by residual pulmonary hypertension. The recurrence of CTEPH after PEA is extremely rare. Consequently, as the first-line treatment for CTEPH, PEA can be performed safely with hemodynamic improvement and favorable early and long-term outcomes, except for potentially high-risk patients with distal lesions, elevated pulmonary vascular resistance, poor exercise capacity, and advanced age. Recently advanced balloon pulmonary angioplasty might be a promising alternative for such difficult patients.
    General Thoracic and Cardiovascular Surgery 09/2013;
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    ABSTRACT: Since the last World Symposium on Pulmonary Hypertension in 2008, we have witnessed numerous and exciting developments in chronic thromboembolic pulmonary hypertension (CTEPH). Emerging clinical data and advances in technology have led to reinforcing and updated guidance on diagnostic approaches to pulmonary hypertension, guidelines that we hope will lead to better recognition and more timely diagnosis of CTEPH. We have new data on treatment practices across international boundaries as well as long-term outcomes for CTEPH patients treated with or without pulmonary endarterectomy. Furthermore, we have expanded data on alternative treatment options for select CTEPH patients, including data from multiple clinical trials of medical therapy, including 1 recent pivotal trial, and compelling case series of percutaneous pulmonary angioplasty. Lastly, we have garnered more experience, and on a larger international scale, with pulmonary endarterectomy, which is the treatment of choice for operable CTEPH. This report overviews and highlights these important interval developments as deliberated among our task force of CTEPH experts and presented at the 2013 World Symposium on Pulmonary Hypertension in Nice, France.
    Journal of the American College of Cardiology 12/2013; 62(25 Suppl):D92-9. · 14.09 Impact Factor