Ann Thorac Surg 2006;82:746-747
© 2006 The Society of Thoracic Surgeons
Case report
Extracorporeal Circulation and Cardiac Arrest in an Awake Patient: A Safe Approach for Single Lung Pulmonary Artery Stenting?
Florian Heid, MDa,*,
Stefan Guth, MDb,
Eckhard Mayer, MDa,
Sascha Herber, MDc,
Christoph Düber, MD, PhDc,
Irene Tzanova, MDa,
Christian Werner, MD, PhDa
a Department of Anesthesiology, Johannes Gutenberg-University, Mainz, Germany
b Department of Cardiothoracic and Vascular Surgery, Johannes Gutenberg-University, Mainz, Germany
c Department of Radiology, Johannes Gutenberg-University, Mainz, Germany
Accepted for publication November 23, 2005.
* Address correspondence to Dr Heid, Department of Anesthesiology, Johannes Gutenberg-University, Langenbeckstr. 1, Mainz, 55131 Germany (Email: heid{at}uni-mainz.de).
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Abstract
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We describe the anesthetic concept and approach in a single lung patient scheduled for pulmonary artery stenting due to recurrence of a pulmonary artery sarcoma after left pneumectomy.
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Introduction
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Pulmonary artery sarcomas are rather rare events. We describe a patient with a history of left pneumectomy due to pulmonary artery sarcoma. Tumor recurrence led to rapid deterioration and this single lung patient was scheduled for pulmonary artery stenting. We focused on the anesthetic management of this exceptional case, which included extracorporeal circulation and cardiac arrest in an awake patient.
A left-sided pneumectomy and thromboendarterectomy of the right pulmonary artery due to primary pulmonary artery sarcoma was performed on a 50-year-old man in November 2003. He was in full remission until May 2005 when his health status rapidly deteriorated with dyspnea and cyanosis leading to emergency hospital admission. Computerized tomography revealed tumor recurrence, reducing the diameter of the right pulmonary artery to pencil size (Fig 1). Corresponding to these findings, his impaired pulmonary blood flow led to facial edema and increased central venous pressure (20 mm Hg). Anatomic conditions excluded any surgical option; hence an endovascular approach with stent graft implantation was planned. Considerations concerning anesthetic management evolved from the need for temporary but complete outflow obstruction in an already dilated and insufficient right ventricle.
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Fig 1. Magnetic resonance angiography before intervention. Note severe stenosis of the right pulmonary artery (white arrow).
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After establishing standard monitoring (ie, electrocardiogram, noninvasive arterial blood pressure, peripheral transcutaneous oxygen saturation), the patient's right radial artery was cannulated and a central venous line through the right internal jugular vein was inserted. After local anesthesia of the left groin (30 mL of mepivacaine, 1%), his femoral artery and vein were catheterized and connected to a cardiopulmonary bypass circuit. During these measures and thereafter the patient was moderately sedated by intravenous infusion of remifentanil (0.06 to 0.1µg kg-1min-1), with preserved spontaneous breathing and undiminished responsiveness, corresponding to a Ramsey score of 2. The right femoral vein was cannulated and an introducer sheath was inserted, and through this a guidewire was advanced. Before the guidewire reached the right atrium extracorporeal circulation (ECC) was started to avoid hemodynamic disturbance in case of potential dysrhythmia. With the onset of the ECC, the ventilatory drive of the patient ceased due to complete extracorporeal oxygenation, and he only breathed if he wanted to talk to a team member. Right atrial and ventricular passage of the guidewire was uneventful, and no dysrhythmias occurred. With the tip of the guidewire in the pulmonary artery a maximum ECC flow (3.5 L/min) could not relieve the heart completely. This was confirmed by a persistent pulsatile flow through the radial arterial line. Therefore, prior to balloon dilatation, we induced cardiac arrest by bolus injection of adenosine (24 mg) through the central venous line. Cardiac arrest lasted for approximately 30 seconds and endovascular maneuvers were performed. Altogether, four temporary arrests were necessary for dilation and stent implantation (Fig 2). Immediately after stent placement, the central venous oxygen saturation increased from 68% to 78%, whereas the central venous pressure decreased to 10 mm Hg. After removal of the central endovascular catheters, the patient was weaned from ECC without difficulty. The femoral cannulas were removed and the groin was closed. During all measures and maneuvers our patient remained responsive and comfortable. The following clinical course of the patient was uneventful and he was discharged 6 days after the intervention.
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Comment
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Primary pulmonary artery sarcoma is a very rare tumor with only a few hundred cases having been reported in the literature [1]. Without surgery the median survival time is 1.5 month. However, surgery can potentially prolong survival time to 10 months [1]. Eighteen months after the first surgical intervention this patient had a tumor recurrence leading to right ventricle outflow obstruction with severe circulatory impairment develop. In the absence of a surgical option, an interventional approach was conceptualized. In this patient there was specific concern that complete right ventricular outflow obstruction during balloon inflation and stent release might result in complete cardiac failure. This led us to select ECC to support systemic and pulmonary circulation during the stent procedure. In addition, transient cardiac arrest was induced to avoid any cardiac disturbance during stent release. Moreover, avoidance of a mediastinal mass syndrome was achieved by deliberately preserving the patient's ability to breathe spontaneously. We believed that general anesthesia and mechanical ventilation might have the potential to obstruct our patient's airway or pulmonary artery by collapsing tumor masses. During the whole procedure the patient was only slightly sedated, and he tolerated the procedure well and felt comfortable. We have found only one comparable case in the literature [2]. To reduce an increase in right ventricular afterload these colleagues also established percutaneous cardiopulmonary support. However they performed the complete procedure under general anesthesia.
We believe that this approach is unique. With the combination of preserved spontaneous breathing, ECC and temporary cardiac arrest, balloon inflation and stent release was safe, yet the technical efforts and expenses may cause controversial viewpoints. However, in a patient whose oxygenation was dependent on only two lobes of a single lung combined with circulatory failure we saw the medical and surgical needs of the patient most safely met with the use of ECC under local anesthesia combined with light sedation.
In selected patients this approach is a safe technique with surprisingly high patient comfort and is an effective alternative to techniques implementing general anesthesia.
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References
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- Anderson MB, Kriett JM, Kapelanski DP, Tarazi R, Jamieson SW. Primary pulmonary artery sarcomaa report of six cases. Ann Thorac Surg 1995;59:1487-1490.[Abstract/Free Full Text]
- Asato Y, Amemiya R, Kiyoshima M, Shioyama Y, Asato M. Pulmonary artery stenting for recurrent lung cancer after left pneumonectomy Ann Thorac Surg 2002;73:1962-1964.[Abstract/Free Full Text]
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Abstract
Introduction
