Anesthesia for Pulmonary Endarterectomy
Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH), a disease that is increasingly being identified as a complication of acute pulmonary embolism. It is a complex surgical procedure involving the removal of obstructive material (including the intima and superficial media) from the pulmonary vasculature and requires cardiopulmonary bypass along with periods of deep hypothermic circulatory arrest. Complications include reperfusion pulmonary edema, pulmonary arterial steal, and persistent pulmonary hypertension, in addition to those common to other open-heart procedures. While PEA is still considered a high-risk surgery performed by only a small number of experienced medical centers, patient morbidity and mortality has significantly improved over the years. Surgical success is greatly dependent not only on surgical expertise, but also on the perioperative care delivered by an experienced cardiac anesthesiologist. This chapter reviews the pathophysiology of CTEPH as well as the pre-, intra-, and post-operative considerations for the anesthetic management of these patients.
KeywordsChronic thromboembolic pulmonary hypertension Pulmonary endarterectomy Pulmonary thromboendarterectomy Reperfusion pulmonary edema Pulmonary arterial steal
- 12.Madani MM, Jamieson SW. Pulmonary embolism and pulmonary thromboendarterectomy. In: Cohn LH, editor. Cardiac surgery in the adult. 4th ed. New York: McGraw-Hill; 2012.Google Scholar
- 19.Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K, Solomon SD, Louie EK, Schiller NB. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23(7):685–713.CrossRefPubMedGoogle Scholar
- 20.Dittrich HC, McCann 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(Supp):135A.Google Scholar
- 21.Thomson B, Tsui SS, Dunning J, Goodwin A, Vuylsteke A, Latimer R, Pepke-Zaba J, Jenkins DP. Pulmonary endarterectomy is possible and effective without the use of complete circulatory arrest—the UK experience in over 150 patients. Eur J Cardiothorac Surg. 2008;33(2):157–63.CrossRefPubMedGoogle Scholar
- 30.Mayer E, Jenkins D, Lindner J, D'Armini A, Kloek J, Meyns B, Ilkjaer LB, Klepetko W, Delcroix M, Lang I, Pepke-Zaba J, Simonneau G, Dartevelle P. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011;141:702–10.CrossRefGoogle Scholar