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Ann Thorac Surg 1999;68:2385-2386
© 1999 The Society of Thoracic Surgeons
a Second Department of Surgery, Kagoshima University Faculty of Medicine, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan
To the Editor
We read with interest the article by Smythe and associates [1] regarding management of exsanguinating hemoptysis during cardiopulmonary bypass (CPB). We congratulate the authors on successful immediate management of such a life-threatening event by rapid airway control with rigid bronchoscopy.
They report the cases of 3 patients with different sources of exsanguinating hemoptysis during CPB. We previously reported a case of massive endobronchial hemorrhage after pulmonary embolectomy [2], which is very similar to that of patient 2 reported by the authors. In our case of recurrent massive pulmonary embolism, extensive clots were removed using forceps, balloon embolectomy catheter, and bolus saline flush with suction under total CPB. Plugged and lodged thrombi in the peripheral pulmonary arteries were then repeatedly squeezed by manual compression of the lungs through the opened mediastinal pleurae. During partial CPB after closure of the pulmonary arteries, we encountered blood gush from an endotracheal tube (1,500 mL of blood for 30 minutes). A flexible fiberoptic bronchoscopy clarified just the bleeding side, but could not show the actual bleeding point. Left thoracotomy through the fourth intercostal space was carried out. Several scarred lesions of pulmonary infarction were found on the surface of the apex of the lung. The lesions were resected by stapling technique with successful hemostasis. The CPB was discontinued without difficulty. The patient left our hospital with slight exertional dyspnea, although he was ventilated for 6 days postoperatively.
Two etiologic factors can be considered in the occurrence of exsanguinating hemoptysis after pulmonary embolectomy. One is pulmonary arterial wall injury by a mechanical factor, that is, the introduction of a balloon embolectomy catheter and suction tip, balloon inflation, and excessively negative pressure in suction. Forced insertion of the embolectomy catheter to the peripheral pulmonary artery and balloon overinflation are frequently the causes of pulmonary artery injury. The injury may result in massive pulmonary parenchymal bleeding and subsequent bleeding into the major airway. In patients with pulmonary hypertension, arterial wall fragility must always be considered. Reperfusion injury is another cause of exsanguinating hemoptysis. After embolectomy, and after the reestablishment of pulmonary blood flow, massive parenchymal and intrabronchial hemorrhage may occur during or after CPB [3], because restoration of flow to severely damaged pulmonary capillaries may cause immediate rupture and result in massive hemorrhage. This hemorrhage begins as a blood-stained edema fluid, which becomes thicker and more blood-like [4]. In our case, the use of a balloon embolectomy catheter, compression of the lung, and possible reperfusion injury were the causes of exsanguinating hemoptysis, judging from the local hemorrhage.
It is very important not only to treat exsanguinating hemoptysis, but also to prevent it. Since recognition of this complication associated with pulmonary embolectomy, we have operated on 12 more cases of embolectomy for acute pulmonary embolism, and have not experienced a case of exsanguinating hemoptysis after embolectomy. Our embolectomy procedure, used during this period, only includes the use of forceps and bolus saline flush through an appropriately sized flexible catheter with gentle suction, to prevent exsanguinating hemoptysis, at least by a mechanical cause. The forceps and the catheter are never forcibly inserted into the peripheral pulmonary artery, and embolectomy catheters and manual compression of the lungs are never used. Our procedure is effective enough to improve the deteriorated situation caused by acute pulmonary embolism, because the thrombi are usually located in the central part of the pulmonary arteries. In addition, surgical pulmonary embolectomy for acute pulmonary embolism is a life-saving procedure.
Finally we are interested in how the authors performed pulmonary embolectomy. They describe only that a large portion of the thromboembolus was removed from both main branch pulmonary arteries, and that patient 2 died shortly of uncontrolled bilateral pulmonary hemorrhage and right ventricular failure, after cessation of CPB.
References
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