Abstract
Objective: The gold standard procedure for pulmonary thromboendarterectomy is median sternotomy, cardiopulmonary bypass, profound hypothermia (18oC) and circulatory arrest. We propose a modified technique to improve the quality of care in this patient population, based on an intervention previously used in aortic surgery. Method: In our modified technique, we cannulated the right axillary artery to allow antegrade brain perfusion while on circulatory arrest. In this retrospective study, we have reviewed the data relating to the first 7 patients on whom we performed the modified technique and have made comparison with a group of 7 case-matched individuals who underwent the standard technique (control group). Results: The modified technique allowed for use of moderate hypothermia (25oC - 28oC). Patients in both groups woke up without neurologic complications. A trend towards, but non-significant reduction in duration of surgery from 303 (±42) to 279 (±44), duration of postoperative inotropic support from 2.7 ± 3.4 days to 1.7 ± 2.0 days, as well as postoperative mechanical ventilation time from 4.87 (±3.7) to 2 (±2.7) days were seen in the control and modified groups respectively. All patients in the modified group woke up on post-operative day 0, whereas most patients in the control group awoke on postoperative day 1. No significant differences were noted in the reduction in preoperative to postoperative systolic pulmonary artery pressure, post-operative length of stay in the intensive care unit and length of stay in the hospital among the two groups. Conclusions: The antegrade brain perfusion via the right axillary artery allows for good brain protection, while maintaining a bloodless field in the arterial pulmonary tree. All our patients awoke without any neurologic deficits. In the future, by using an even milder level of cooling, we may be able to significantly reduce the duration of surgery and improve the recovery of our patients.
Highlights
Pulmonary thromboendarterectomy (PTE) offers a surgical cure for pulmonary hypertension due to thromboembolic disease [1]
The antegrade brain perfusion via the right axillary artery allows for good brain protection, while maintaining a bloodless field in the arterial pulmonary tree
We present our results in 7 patients who underwent selective antegrade brain perfusion at moderate hypothermia
Summary
Pulmonary thromboendarterectomy (PTE) offers a surgical cure for pulmonary hypertension due to thromboembolic disease [1]. The standard technique for thromboendarterectomy, as developed at the University of San Diego (UCSD), involves median sternotomy, cardiopulmonary bypass and intermittent periods of deep hypothermic circulatory arrest (DHCA) to 18 ̊C [1]. Using this method, the UCSD group reported 17% operative mortality in their first 200 cases but have decreased it to below 5% in the last 500, suggesting a learning curve associated with the procedure [2]. We hypothesize that DHCA is associated with increased postoperative wake up time, mechanical ventilation time and longer use of postoperative inotropic support
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