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Anesthesia for Pulmonary Thromboendarterectomy

  • Timothy M. MausEmail author
  • Dalia Banks
Chapter

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.

Keywords

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)

References

  1. 1.
    Moser KM, Houk VN, Jones RC, Hufnagel CC. Chronic, massive thrombotic obstruction of the pulmonary arteries: analysis of four operated cases. Circulation. 1965;32(3):377–85.CrossRefGoogle Scholar
  2. 2.
    McLaughlin VV, Langer A, Tan M, et al. Contemporary trends in the diagnosis and management of pulmonary arterial hypertension. Chest. 2013;143(2):324–32.CrossRefGoogle Scholar
  3. 3.
    Moser KM, Auger WR, Fedullo PF. Chronic major-vessel thromboembolic pulmonary hypertension. Circulation. 1990;81(6):1735–43.CrossRefGoogle Scholar
  4. 4.
    Jamieson SW, Kapelanski DP. Pulmonary endarterectomy. Curr Probl Surg. 2000;37(3):165–252.CrossRefGoogle Scholar
  5. 5.
    DeMonaco NA, Dang Q, Kapoor WN, Ragni MV. Pulmonary embolism incidence is increasing with use of spiral computed tomography. Am J Med. 2008;121(7):611–7.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Lindblad B, Eriksson A, Bergqvist D. Autopsy-verified pulmonary embolism in a surgical department: analysis of the period from 1951 to 1988. Br J Surg. 1991;78(7):849–52.CrossRefGoogle Scholar
  7. 7.
    Riedel M, Stanek V, Widimsky J, Prerovsky I. Longterm follow-up of patients with pulmonary thromboembolism. Chest. 1982;81(2):151–8.CrossRefGoogle Scholar
  8. 8.
    Rich S Rubin L, Abenhail L, et al. Executive summary from the World Symposium on Primary Pulmonary Hypertension. Paper presented at: World Symposium on Primary Pulmonary Pulmonary Hypertension; September 6–10, 1998, Evian; 1998.Google Scholar
  9. 9.
    Galie N, Hoeper MM, Humbert M, et al. Guidelines for the diagnosis and treatment of pulmonary hypertension. Eur Respir J. 2009;34(6):1219–63.CrossRefGoogle Scholar
  10. 10.
    Dadfarmay S, Berkowitz R, Kim B, Manchikalapudi RB. Differentiating pulmonary arterial and pulmonary venous hypertension and the implications for therapy. Congest Heart Fail. 2010;16(6):287–91.CrossRefGoogle Scholar
  11. 11.
    Bossone E, D’Andrea A, D’Alto M, et al. Echocardiography in pulmonary arterial hypertension: from diagnosis to prognosis. J Am Soc Echocardiogr. 2013;26(1):1–14.CrossRefGoogle Scholar
  12. 12.
    Bernard J, Yi ES. Pulmonary thromboendarterectomy: a clinicopathologic study of 200 consecutive pulmonary thromboendarterectomy cases in one institution. Hum Pathol. 2007;38(6):871–7.CrossRefGoogle Scholar
  13. 13.
    Guillinta P, Peterson KL, Ben-Yehuda O. Cardiac catheterization techniques in pulmonary hypertension. Cardiol Clin. 2004;22(3):401–15.CrossRefGoogle Scholar
  14. 14.
    Post MC, Plokker HWM, Kelder JC, Snijder RJ. Long-term efficacy of bosentan in inoperable chronic thromboembolic pulmonary hypertension. Neth Hear J. 2009;17(9):329–33.CrossRefGoogle Scholar
  15. 15.
    Vassallo FG, Kodric M, Scarduelli C, et al. Bosentan for patients with chronic thromboembolic pulmonary hypertension. Eur J Intern Med. 2009;20(1):24–9.CrossRefGoogle Scholar
  16. 16.
    Jaïs X, D’Armini AM, Jansa P, et al. Bosentan for treatment of inoperable chronic thromboembolic pulmonary hypertension. J Am Coll Cardiol. 2008;52(25):2127–34.CrossRefGoogle Scholar
  17. 17.
    Dalen JE, Alpert JS. Natural history of pulmonary embolism. Prog Cardiovasc Dis. 1975;17(4):259–70.CrossRefGoogle Scholar
  18. 18.
    Pengo V, Lensing AWA, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350(22):2257–64.CrossRefGoogle Scholar
  19. 19.
    Fedullo PF, Auger WR, Kerr KM, Rubin LJ. Chronic thromboembolic pulmonary hypertension. N Engl J Med. 2001;345(20):1465–72.CrossRefGoogle Scholar
  20. 20.
    Bonderman D, Turecek PL, Jakowitsch J, et al. High prevalence of elevated clotting factor VIII in chronic thromboembolic pulmonary hypertension. Thromb Haemost. 2003;90:372–6.CrossRefGoogle Scholar
  21. 21.
    Lang IM. Chronic thromboembolic pulmonary hypertension — not so rare after all. N Engl J Med. 2004;350(22):2236–8.CrossRefGoogle Scholar
  22. 22.
    Kapitän KS, Buchbinder M, Wagner PD, Moser KM. Mechanisms of hypoxemia in chronic thromboembolic pulmonary hypertension. Am Rev Respir Dis. 1989;139(5):1149–54.CrossRefGoogle Scholar
  23. 23.
    Moser KM. Thromboendarterectomy for chronic, major-vessel thromboembolic pulmonary hypertension. Ann Intern Med. 1987;107(4):560.CrossRefGoogle Scholar
  24. 24.
    D’Armini AM, Zanotti G, Ghio S, et al. Reverse right ventricular remodeling after pulmonary endarterectomy. J Thorac Cardiovasc Surg. 2007;133(1):162–8.CrossRefGoogle Scholar
  25. 25.
    Reichelt A, Hoeper MM, Galanski M, Keberle M. Chronic thromboembolic pulmonary hypertension: evaluation with 64-detector row CT versus digital substraction angiography. Eur J Radiol. 2009;71(1):49–54.CrossRefGoogle Scholar
  26. 26.
    Suga K, Kawakami Y, Iwanaga H, Hayashi N, Seto A, Matsunaga N. Comprehensive assessment of lung CT attenuation alteration at perfusion defects of acute pulmonary thromboembolism with breath-hold SPECT-CT fusion images. J Comput Assist Tomogr. 2006;30(1):83–91.CrossRefGoogle Scholar
  27. 27.
    Nikolaou K, Schoenberg SO, Attenberger U, et al. Pulmonary arterial hypertension: diagnosis with fast perfusion MR imaging and high-spatial-resolution MR angiography—preliminary experience. Radiology. 2005;236(2):694–703.CrossRefGoogle Scholar
  28. 28.
    Jensen KW, Kerr KM, Fedullo PF, et al. Pulmonary hypertensive medical therapy in chronic thromboembolic pulmonary hypertension before pulmonary thromboendarterectomy. Circulation. 2009;120(13):1248–54.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Archer SL, Michelakis ED. Phosphodiesterase type 5 inhibitors for pulmonary arterial hypertension. N Engl J Med. 2009;361(19):1864–71.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Rubin LJ, Badesch DB, Barst RJ. Bosentan therapy for pulmonary arterial hypertension. ACC Curr J Rev. 2002;11(5):30.CrossRefGoogle Scholar
  31. 31.
    Confalonieri M, Kodric M, Longo C, Vassallo FG. Bosentan for chronic thromboembolic pulmonary hypertension. Expert Rev Cardiovasc Ther. 2009;7(12):1503–12.CrossRefGoogle Scholar
  32. 32.
    Nagaya N, Sasaki N, Ando M, et al. Prostacyclin therapy before pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension*. Chest. 2003;123(2):338–43.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Ono F, Nagaya N, Okumura H, et al. Effect of orally active prostacyclin analogue on survival in patients with chronic thromboembolic pulmonary hypertension without major vessel obstruction. Chest. 2003;123(5):1583–8.CrossRefGoogle Scholar
  34. 34.
    Vizza CD, Badagliacca R, Sciomer S, et al. Mid-term efficacy of Beraprost, an Oral prostacyclin analog, in the treatment of distal CTEPH: a case control study. Cardiology. 2006;106(3):168–73.CrossRefGoogle Scholar
  35. 35.
    Augoustides JG, Culp K, Smith S. Rebound pulmonary hypertension and cardiogenic shock after withdrawal of inhaled prostacyclin. Anesthesiology. 2004;100(4):1023–5.CrossRefGoogle Scholar
  36. 36.
    Jamieson SW. Pulmonary thromboendarterectomy. Heart. 1998;79(2):118–20.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Fedullo PF, Auger WR, Channick RN, Moser KM, Jamieson SW. Chronic thromboembolic pulmonary hypertension. Clin Chest Med. 1995;16(2):353–74.Google Scholar
  38. 38.
    Jamieson SW, Auger WR, Fedullo PF, et al. Experience and results with 150 pulmonary thromboendarterectomy operations over a 29-month period. J Thorac Cardiovasc Surg. 1993;106(1):116–26; discussion 126–7.Google Scholar
  39. 39.
    Madani M. Surgical Treatment of Chronic Thromboembolic Pulmonary Hypertension: Pulmonary Thromboendarterectomy. Methodist Debakey Cardiovasc J. 2016; 12(4): 213–218.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Rich S, Gubin S, Hart K. The effects of phenylephrine on right ventricular performance in patients with pulmonary hypertension. Chest. 1990;98(5):1102–6.CrossRefGoogle Scholar
  41. 41.
    Cronin B, Robbins R, Maus T. Pulmonary artery catheter placement using transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2017;31(1):178–83.CrossRefGoogle Scholar
  42. 42.
    Manecke GR, Parimucha M, Stratmann G, et al. Deep hypothermic circulatory arrest and the femoral-to-radial arterial pressure gradient. J Cardiothorac Vasc Anesth. 2004;18(2):175–9.CrossRefGoogle Scholar
  43. 43.
    Mohr R, Lavee J, Goor D. Inaccuracy of radial artery pressure measurement after cardiac operations. Surv Anesthesiol. 1988;32(1):1.CrossRefGoogle Scholar
  44. 44.
    Urzua J. Aortic-to-radial arterial pressure gradient after bypass. Anesthesiology. 1990;73(1):191.CrossRefGoogle Scholar
  45. 45.
    Dittrich HC, McConn HA, Wilson WC. Identification of interatrial communication in patients with elevated right atrial pressure using surface and transesophageal contrast echocardiography. J Am Coll Cardiol. 1993;21(Suppl):135A.Google Scholar
  46. 46.
    Schuhmann MU, Suhr DF, v Gösseln HH, Bräuer A, Jantzen J-P, Samii M. Local brain surface temperature compared to temperatures measured at standard extracranial monitoring sites during. J Neurosurg Anesthesiol. 1999;11(2):90–5.CrossRefGoogle Scholar
  47. 47.
    Riess F-C, Löwer C, Seelig C, et al. Recombinant hirudin as a new anticoagulant during cardiac operations instead of heparin: successful for aortic valve replacement in man. J Thorac Cardiovasc Surg. 1995;110(1):265–7.CrossRefGoogle Scholar
  48. 48.
    Pötzsch B, Hund S, Madlener K, Unkrig C, Müller-Berghaus G. Monitoring of recombinant hirudin: assessment of a plasma-based ecarin clotting time assay. Thromb Res. 1997;86(5):373–83.CrossRefGoogle Scholar
  49. 49.
    von Segesser LK, Mueller X, Marty B, Horisberger J, Corno A. Alternatives to unfractioned heparin for anticoagulation in cardiopulmonary bypass. Perfusion. 2001;16(5):411–6.CrossRefGoogle Scholar
  50. 50.
    Warkentin TE, Greinacher A. Heparin-induced thrombocytopenia and cardiac surgery. Ann Thorac Surg. 2003;76(2):638–48.CrossRefGoogle Scholar
  51. 51.
    Vanderlinden J, Ekroth R, Lincoln C, Pugsley W, Scallan M, Tyden H. Is cerebral blood flow/metabolic mismatch during rewarming a risk factor after profound hypothermic procedures in small children? Eur J Cardiothorac Surg. 1989;3(3):209–15.CrossRefGoogle Scholar
  52. 52.
    Yoshitani K, Kawaguchi M, Sugiyama N, et al. The association of high jugular bulb venous oxygen saturation with cognitive decline after hypothermic cardiopulmonary bypass. Anesth Analg. 2001;92:1370–6.CrossRefGoogle Scholar
  53. 53.
    Henson LC, Calalang C, Temp JA, Ward DS. Accuracy of a cerebral oximeter in healthy volunteers under conditions of Isocapnic hypoxia. Anesthesiology. 1998;88(1):58–65.CrossRefGoogle Scholar
  54. 54.
    Daubeney PEF, Pilkington SN, Janke E, Charlton GA, Smith DC, Webber SA. Cerebral oxygenation measured by near-infrared spectroscopy: comparison with jugular bulb oximetry. Ann Thorac Surg. 1996;61(3):930–4.CrossRefGoogle Scholar
  55. 55.
    Chen CSLN, Liu K. Detection of cerebral desaturation during cardiopulmonary bypass by cerebral oximetry. Acta Anaesthesiol Sin. 1997;35(1):59.Google Scholar
  56. 56.
    Manecke GR, Kotzur A, Atkins G, et al. Massive pulmonary hemorrhage after pulmonary thromboendarterectomy. Anesth Analg. 2004;99(3):672–5.CrossRefGoogle Scholar
  57. 57.
    Dittrich HC, Nicod PH, Chow LC, Chappuis FP, Moser KM, Peterson KL. Early changes of right heart geometry after pulmonary thromboendarterectomy. J Am Coll Cardiol. 1988;11(5):937–43.CrossRefGoogle Scholar
  58. 58.
    Dittrich HC, Chow LC, Nicod PH. Early improvement in left ventricular diastolic function after relief of chronic right ventricular pressure overload. Circulation. 1989;80(4):823–30.CrossRefGoogle Scholar
  59. 59.
    Cronin B, Maus T, Pretorius V, et al. Case 13 – 2014: management of pulmonary hemorrhage after pulmonary endarterectomy with venovenous extracorporeal membrane oxygenation without systemic anticoagulation. J Cardiothorac Vasc Anesth. 2014;28(6):1667–76.CrossRefGoogle Scholar
  60. 60.
    Levinson RM, Shure D, Moser KM. Reperfusion pulmonary edema after pulmonary artery thromboendarterectomy. Am Rev Respir Dis. 1986;134(6):1241–5.Google Scholar
  61. 61.
    Thistlethwaite PA, Madani MM, Kemp AD, Hartley M, Auger WR, Jamieson SW. Venovenous extracorporeal life support after pulmonary endarterectomy: indications, techniques, and outcomes. Ann Thorac Surg. 2006;82(6):2139–45.CrossRefGoogle Scholar
  62. 62.
    Berman M, Tsui S, Vuylsteke A, et al. Successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy. Ann Thorac Surg. 2008;86(4):1261–7.CrossRefGoogle Scholar
  63. 63.
    Olman MA, Auger WR, Fedullo PF, Moser KM. Pulmonary vascular steal in chronic thromboembolic pulmonary hypertension. Chest. 1990;98(6):1430–4.CrossRefGoogle Scholar
  64. 64.
    Moser KM, Metersky ML, Auger WR, Fedullo PF. Resolution of vascular steal after pulmonary Thromboendarterectomy. Chest. 1993;104(5):1441–4.CrossRefGoogle Scholar
  65. 65.
    Thistlethwaite PA, Kaneko K, Madani MM, Jamieson SW. Technique and outcomes of pulmonary endarterectomy surgery. Ann Thorac Cardiovasc Surg. 2008;14(5):274–82.Google Scholar
  66. 66.
    Edwards EB, Roberts JP, McBride MA, Schulak JA, Hunsicker LG. The effect of the volume of procedures at transplantation centers on mortality after liver transplantation. N Engl J Med. 1999;341(27):2049–53.CrossRefGoogle Scholar
  67. 67.
    Menzel T, Kramm T, Mohr-Kahaly S, Mayer E, Oelert H, Meyer J. Assessment of cardiac performance using Tei indices in patients undergoing pulmonary thromboendarterectomy. Ann Thorac Surg. 2002;73(3):762–6.CrossRefGoogle Scholar
  68. 68.
    Thistlethwaite PA, Madani M, Jamieson SW. Outcomes of pulmonary endarterectomy surgery. Semin Thorac Cardiovasc Surg. 2006;18(3):257–64.CrossRefGoogle Scholar
  69. 69.
    Madani MM, Auger WR, Pretorius V, et al. Pulmonary endarterectomy: recent changes in a single institution’s experience of more than 2,700 patients. Ann Thorac Surg. 2012;94(1):97–103. discussion 103CrossRefGoogle Scholar
  70. 70.
    Corsico AG, D’Armini AM, Cerveri I, et al. Long-term outcome after pulmonary endarterectomy. Am J Respir Crit Care Med. 2008;178(4):419–24.CrossRefGoogle Scholar

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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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