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Anesthesia for Pulmonary Thromboendarterectomy

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Principles and Practice of Anesthesia for Thoracic Surgery

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Abstract

Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by obstruction of major pulmonary arteries due to unresolved or recurrent pulmonary emboli leading to pulmonary hypertension (Moser et al., Circulation 32(3):377–385, 1965; McLaughlin et al., Chest 143(2):324–332, 2013). Pulmonary thromboendarterectomy is an endarterectomy of the proximal pulmonary vascular tree and is the treatment of choice for chronic thromboembolic pulmonary hypertension. Each year, there are between 500 and 2500 patients diagnosed with CTEPH, an estimated 0.1–0.5% of patients who survive pulmonary embolism (Moser et al., Circulation 81(6):1735–1743, 1990; Jamieson and Kapelanski, Curr Probl Surg 37(3):165–252, 2000)

The most common presenting symptom of chronic thromboembolic pulmonary hypertension is exertional dyspnea. The diagnosis is confirmed with echocardiography, right-sided cardiac catheterization, and pulmonary angiogram. Patients with CTEPH, when left untreated, develop a small vessel vasculopathy that mimics idiopathic pulmonary hypertension. Perioperative monitoring includes femoral and radial arterial pressures, processed EEG, pulmonary artery pressures, and transesophageal echocardiography. Anesthetic induction and maintenance are tailored to hemodynamic stability, right ventricular coronary perfusion pressure, and right ventricular support. A multidisciplinary approach is important for the success of this operation involving the specialties of surgery, pulmonary medicine, critical care, cardiology, anesthesiology, and radiology.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, University of California San Diego Health, La Jolla, CA, USA

    Timothy M. Maus & Dalia Banks

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  1. Timothy M. Maus
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  2. Dalia Banks
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Correspondence to Timothy M. Maus .

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Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Electronic Supplementary Material

Transgastric short-axis view demonstrated severe right ventricular enlargement and a deviated interventricular septum (MP4 2592 kb) (MP4 728 kb)

Midesophageal four-chamber view demonstrating a dilated right heart, deviated septum, and underfilled left heart (MP4 625 kb)

Midesophageal ascending aortic short-axis view demonstrating thromboembolic material at the origin of the right pulmonary artery (MP4 2592 kb)

Midesophageal four-chamber view in a patient with CTEPH prior to pulmonary thromboendarterectomy. Note the dilated right heart, deviated septums, and underfilled left heart (MP4 630 kb)

Midesophageal four-chamber view of the same patient status post-pulmonary thromboendarterectomy and tricuspid valve repair. Note the decompression of the RA and RV with increased left heart size (MP4 313 kb)

Clinical Case Discussion

Case: A 68-year-old woman with CTEPH underwent a PTE and has just been separated from CPB. The surgeon tells you that the endarterectomy was difficult because it was Type 3 disease and the thromboembolic material was particularly “sticky.” You suspected such because the surgeon required two circulatory arrests on the right side, and he usually requires only one on each side. Large amounts of dark blood appear in the endotracheal tube as you begin ventilating.

Questions

  • What is the most likely cause of this bleeding?

  • What diagnostic maneuvers can be performed to determine the cause and location of the bleeding?

  • What are the therapeutic options, and how will they be chosen?

The most likely cause is surgical trauma, puncture of the distal pulmonary arteries resulting from aggressive endarterectomy. Other possibilities include nonsurgical PA rupture (high pressure, PA catheter trauma). Initial maneuvers include reinstitution of CPB including decompression of the pulmonary arterial tree with a PA vent, thereby temporarily reducing the amount of airway bleeding. Fiberoptic bronchoscopy can assist in localizing the site of the bleeding. Smaller bleeds may be managed with lung isolation, separation from CPB, reversal of heparin, as well as correction of coagulopathies. Lung isolation techniques include double-lumen tubes and bronchial blockers. A preferred technique is to exchange the endotracheal tube for a larger size (i.e., 9.0 mm ETT) to allow a bronchial blocker and a larger adult-sized bronchoscope simultaneously. The use of a pediatric size scope yields a smaller suction channel. Attempts to place the bronchial blocker in a subsegment if possible should be sought to maximize the amount of salvaged lung and prevent spillage of blood into the remaining segments. Larger pulmonary hemorrhage events or those associated with worsening hypoxia and hypercarbia may require ECMO. The decision for the method of ECMO rests on the hemodynamic status of the patient with TEE evidence of ventricular dysfunction playing a key role. Assuming biventricular function is intact, venovenous ECMO may be instituted via a single cannula placed percutaneously through the right internal jugular vein. This approach allows for ECMO support with minimal anticoagulation [59]. An algorithm for management of post-CPB hemorrhage is presented in Fig. 49.11.

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Maus, T.M., Banks, D. (2019). Anesthesia for Pulmonary Thromboendarterectomy. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_49

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_49

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