Anesthesia for Pulmonary Thromboendarterectomy

  • Timothy M. MausEmail author
  • Dalia Banks


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.


Hypertension Artery Multidisciplinary Cardiology Vascular tree Small vessel 

Supplementary material

Video 49.1

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

Video 49.2

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

Video 49.3

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

Video 49.4

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)

Video 49.5

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)


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© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of AnesthesiologyUniversity of California San Diego HealthLa JollaUSA

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