Ann Thorac Surg 2006;82:2145-2146
© 2006 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Johannes M. Albes, MD, PhD
Department of Cardiothoracic and Vascular Surgery, Heart Center Brandenburg, Ladeburger Strasse 17, Bernau, 16321 Germany
(Email: j.albes{at}immanuel.de).
Pulmonary endarterectomy for chronic pulmonary thromboembolism is one of the truly challenging surgical procedures in contemporary cardiothoracic surgery. Ever since Houk and colleagues [1] first reported successful treatment of chronic thrombotic pulmonary obstruction, continuous progress has been made in developing safe and efficient surgical strategies to deal with peripheral pulmonary thrombi tightly adherent to a fragile pulmonary vessel wall [2]. It is the merit of Stuart Jamieson and his predecessors in San Diego who developed this technique and demonstrated the value of this operation on a large scale. Today, the interdisciplinary effort of a senior surgeon accompanied by a skillful anesthesiologist, who knows exactly how to handle the heart and lung during several periods of deep hypothermic arrest, provides consistent and reliable results. Inevitably, however, a small proportion of these patients have pulmonary reperfusion injury develop with dire consequences.
Thistlethwaite and colleagues [3] can be commended for an extensive and thorough study utilizing a vast database comprising almost 1,800 patients. She retrieved 20 patients who were supported by artificial oxygenation for pulmonary failure. Thirty percent survived, which does not sound impressive in the first instance. However, without such measures, probably all of them would have died. Although the heart can be entirely replaced by an artificial organ, the lung can not. Nonetheless, extracorporeal membrane oxygenation (ECMO) has been adopted for pulmonary failure after lung transplantation and adult respiratory distress syndrome (ARDS) as well. By doubling the oxygenator’s surface area, current devices can adequately support gas exchange. Because carbon dioxide diffuses 20 times faster than oxygen across a semi-permeable membrane, the primary benefit lies in CO2 elimination rather than oxygen supply. However, this is a worthwhile goal particularly in a veno-venous circuit. As a consequence, the barotrauma of excessive ventilation pressures can be avoided to reduce further damage to the lung. However, humans are not cyborgs. The inherent risks of any assist device such as bleeding, coagulopathy, and inflammation must be balanced against the assumed benefit. Conventional strategies to optimize pulmonary ventilation and perfusion such as prone positioning or a rotational bed can be considered as the first option [4]. In the end, however, one may very much appreciate having extracorporeal oxygenation at hand. Dr. Thistlethwaite and colleagues [3] deserve credit for providing evidence in favor of this rescuing straw.
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References
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- Houk VN, Hufnagel CA, McClenathan JE, Moser KM. Chronic thrombotic obstruction of major pulmonary arteriesReport of a case successfully treated by thrombendarterectomy, and a review of the literature. Am J Med 1963;35:269-282.[Medline]
- Bengtsson L, Henze A, Holmgren A, Bjork VO. Thrombendarterectomy in chronic pulmonary embolism: reports of 3 cases Scand J Thorac Cardiovasc Surg 1986;20(1):67-70.[Medline]
- 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;82:2139-2146.[Abstract/Free Full Text]
- Hess DR. Patient positioning and ventilator-associated pneumonia Respir Care 2005;50(7):892-898discussion 898-9.[Medline]
Related Article
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Venovenous Extracorporeal Life Support After Pulmonary Endarterectomy: Indications, Techniques, and Outcomes
- Patricia A. Thistlethwaite, Michael M. Madani, Aaron D. Kemp, Mary Hartley, William R. Auger, and Stuart W. Jamieson
Ann. Thorac. Surg. 2006 82: 2139-2145.
[Abstract]
[Full Text]
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