Ann Thorac Surg 2006;82:314-316
© 2006 The Society of Thoracic Surgeons
Case report
Two Cases of Chronic Pulmonary Thromboembolism Saved by Postoperative Use of a Percutaneous Cardiopulmonary Support Device
Masato Sato, MD, PhD
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,
Motomi Ando, MD, PhD,
Akihito Muto, MD, PhD,
Yuka Kondo, MD, PhD,
Ryo Hoshino, MD, PhD,
Toshiya Nishibe, MD, PhD,
Mitsuru Yamashita, MD
Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
Accepted for publication August 29, 2005.
* Address correspondence to Dr Sato, Department of Cardiovascular Surgery, Fujita Health University, 1-98, Dengakugakubo, Kutsukake-cho, Toyoake, Aichi, 470-1192 Japan (Email: mssato{at}fujita-hu.ac.jp).
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Abstract
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We performed pulmonary thromboendarterectomy under deep hypothermic intermittent circulatory arrest in 18 patients with chronic pulmonary thromboembolism from August 2001 to January 2004. In some of these cases, reperfusion pulmonary edema prevented a satisfactory improvement in hemodynamic data soon after the surgery. Here we report two cases of chronic pulmonary thromboembolism in which we successfully prevented postoperative persistent pulmonary hypertension and hypoxia caused by severe reperfusion pulmonary edema by the use of a percutaneous cardiopulmonary support device.
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Introduction
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The medical treatment for chronic pulmonary thromboembolism with pulmonary hypertension is limited, and recently, surgical treatment has been more widespread. We performed pulmonary thromboendarterectomy under deep hypothermic intermittent circulatory arrest in 18 patients with chronic pulmonary thromboembolism (CPTE) from August 2001 to January 2004. In most of the cases in which the surgery was successful, hemodynamic data such as the mean pulmonary arterial pressure and pulmonary vascular resistance were significantly improved at the postoperative examination. However, in some of the cases, reperfusion pulmonary edema (RPE) prevented a satisfactory improvement in hemodynamics soon after surgery. Here we report two cases of CPTE in which we successfully prevented postoperative persistent pulmonary hypertension and hypoxia caused by RPE by using a percutaneous cardiopulmonary support (PCPS) device.
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Case Reports
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Patient 1
A 27-year-old man was referred to our hospital for surgery for CPTE from another university hospital. He had suffered from symptoms such as dyspnea and tachycardia since the age of 16 years. When he was 24 years old, he was diagnosed with CPTE and also with antithrombin III deficiency, and medical treatment was started. On admission to our hospital, his liver was palpable (approximately 6 cm) and a murmur of tricuspid regurgitation was strongly audible. The chest roentgenogram examination showed remarkable cardiomegaly (cardiothoracic ratio, 0.72). Pulmonary arteriography demonstrated stenoses in lobar arteries and multiple occlusions and stenoses in segmental arteries. A lung perfusion scintigraphy revealed multiple defects in the bilateral lungs. Serum AT-III activity was 41%, and B-type natriuretic peptide level was 622 pg/mL. Because ultrasonography in the lower limbs detected deep vein thrombosis, an inferior vena cava filter was inserted preoperatively. Table 1
lists his preoperative respiratory and hemodynamic data.
Patient 2
A 28-year-old woman whose chief complaint was dyspnea on exertion had been diagnosed with CPTE 5 years previously, and she was medically treated at another university hospital. She was also diagnosed with a protein C deficiency. Her symptoms were resistant to the medical treatment, so she opted for surgical intervention at our hospital. A pulmonary arteriography showed lobar arteries and multiple occlusions and stenoses in the segmental arteries. A lung perfusion scintigraphy revealed multiple defects in the bilateral lungs. Serum protein C activity was 56%, and B-type natriuretic peptide level was 247 pg/mL. Ultrasonography in the lower limbs did not detect deep thrombosis. Table 1 lists her preoperative respiratory and hemodynamic data.
Pulmonary thromboendarterectomy with extracorporeal circulation under deep hypothermic intermittent circulatory arrest was performed in both cases, and tricuspid annuloplasty was conducted following the method of De Vega in patient 1. The total circulatory arrest duration in patients 1 and 2 was 76 and 50 minutes, respectively, and the cardiac arrest duration was 171 and 123 minutes, respectively. Although the organized thrombi were adequately extracted from the pulmonary arteries of both patients, we could not remove the extracorporeal circulation because of persistent deep pulmonary hypertension (mean pulmonary arterial pressures were almost the same as the systemic arterial pressures when the extracorporeal circulation device was stopped). For the weaning of extracorporeal circulation, we introduced the PCPS devices (CAPIOX® emergency bypass system [Terumo Inc, Tokyo, Japan]) immediately in both cases. Our PCPS circuit consists of a centrifugal pump, a hollow-fiber microporous membrane oxygenator, and percutaneous thin-walled cannulas. All blood-contacting surfaces of both systems were coated with heparin. A 19-French arterial cannula and a 21-French venous cannula were inserted percutaneously into the femoral artery and vein, respectively. After returning to the intensive care unit, we continued to support the circulation by a PCPS device at a flow rate of 3 to 4 mL/min. Intravenous heparin was used to maintain the activated clotting time at greater than 150 seconds. Concomitantly, the subjects were put on an intravenous drip of prostaglandin I2 and catecholamines. Patients 1 and 2 were weaned from the PCPS device on postoperative days 2 and 5, respectively. Although patients 1 and 2 required respiratory control for 22 and 12 days after the operation, respectively, they were discharged from the hospital without complications. Table 2
lists the postoperative outcome and hemodynamic and respiratory data for both patients. Pulmonary arterial pressure and pulmonary vascular resistance were reduced, and the clinical symptoms markedly improved. Postoperative B-type natriuretic peptide levels had also decreased (260 and 32 pg/mL in patients 1 and 2, respectively).
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Comment
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CPTE is a serious disease that induces hypoxemia and pulmonary hypertension, which eventually lead to respiratory or right heart failure, or both. Generally CPTE is resistant to medical treatment, and hence the necessity of surgical treatment has been suggested. Pulmonary thromboendarterectomy is performed frequently as the treatment for CPTE with good outcomes [1].
In general, surgical indication for CPTE include a mean pulmonary arterial pressure of at least 30 mm Hg, a pulmonary vascular resistance of at least 300 dyne · sec-1
· cm-5 or more, thrombi that can be approached surgically, and the preservation of pulmonary function without severe complications [2]. The two patients presented in this article were good candidates for surgical treatment.
Pulmonary thromboendarterectomy has been regarded as a promising, potentially curative surgical procedure. However, this procedure is associated with a specific postoperative complication, RPE, which leads to a considerable reported mortality of 7% to 24% [3, 4]. Reperfusion pulmonary edema is characterized by sustained arterial hypoxemia caused by focal pulmonary infiltrates in regions distal to vessels subjected to endarterectomy [5]. Furthermore, serious RPE induces high pulmonary vascular resistance and right heart failure resulting in persistent pulmonary hypertension. Reperfusion pulmonary edema is sometimes encountered after a technically perfect operation. Both patients described in this article were considered to have developed severe RPE, persistent pulmonary hypertension, and hypoxia after thromboendarterectomy, which resulted in failed weaning from extracorporeal circulation. This led to a requirement for the mechanical support of PCPS. The PCPS is believed to be the most suitable tool for this situation because it can be easily introduced percutaneously in a short time (about 10 minutes), improve the oxygenation, and reduce the pulmonary arterial pressure. Bleeding and thrombus formation are the possible complications. We believe that when the activated clotting time is controlled within the favorable range (150 to 200 seconds) that these complications will not occur as often. But the duration of PCPS should be minimized. The indicators for weaning PCPS are disappearance of congestive shadow on the chest roentgenogram, hemodynamic stability without a massive dose of catecholamines, even under the low flow support (<1.0 L/min) by PCPS.
Nevertheless, we were able to successfully manage this difficult situation because the cause of hemodynamic and respiratory failure was RPE, and not a microscopic distal arteriolar vasculopathy such as primary pulmonary hypertension.
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References
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- Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomyexperience and lessons learned in 1500 cases. Ann Thorac Surg 2003;76:1457-1464.[Abstract/Free Full Text]
- 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;106:116-127.[Abstract]
- Hartz RS, Byrne JG, Levitsky S, et al. Predictors of mortality in pulmonary thromboendarterectomy Ann Thorac Surg 1996;62:1255-1260.[Abstract/Free Full Text]
- Mayer E, Dahm M, Hake U, et al. Mid-term results of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension Ann Thorac Surg 1996;61:1788-1792.[Abstract/Free Full Text]
- Mares P, Gilbert TB, Tschernko EM, et al. Pulmonary artery thromboemdarterectomya comparison of two different postoperative treatment strategies. Anesth Analg 2000;90:267-273.[Abstract/Free Full Text]
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Abstract
Introduction
