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Division of Cardiothoracic Surgery (H-892), University of California Medical Center, 200 W Arbor Dr, No. 8892, San Diego, CA 92103-8892
(Email: sjamieson{at}ucsd.edu; mmadani{at}ucsd.edu).
The Papworth group [1] should be congratulated for their success in the complex endeavor of pulmonary endarterectomy. Here they report their experience with the management of cardiopulmonary collapse after pulmonary thromboendarterectomy (PTE) using central extracorporeal membrane oxygenation (ECMO) support. Although there are some differences between our techniques in performing PTE and our management of postoperative cardiorespiratory failure, the fundamentals remain the same: the treatment for chronic pulmonary hypertension is the surgical removal of the disease by means of endarterectomy, and some patients with severe postoperative cardiopulmonary compromise can be saved by means of extracorporeal support.
From our experience now of some 2500 patients operated on for this condition during the last 20 years, we believe that there is no disease that is "surgically inaccessible," there is no degree of right heart failure that is irreversible, and no pulmonary vascular resistance that is too high to prevent operation. However, it is clear to us that complete resolution of all obstructing material is the key to success, and we are in no doubt that to perform a complete endarterectomy of every vessel in the distal subsegmental vasculature, circulatory arrest is always necessary. It is difficult to understand the imperative to seek alternative methods when this technique as currently applied has no adverse sequelae and is so successful.
As for the use of extracorporeal circulatory support we prefer the use of venovenous cannulation (VV-extracorporeal CO2 removal) in patients who have normal cardiac function. The venoarterial technique should be reserved for select patents who also have hemodynamic compromise, as was the case for most patients in this article. Our previously published report concerned only results with the venovenous technique.
If a patient is unstable coming off cardiopulmonary bypass, there is no choice but to use venoarterial ECMO, and the most convenient way is to proceed with central cannulation. This is not to be confused with the patient who is hemodynamically stable but who presents with severe reperfusion injury with poor oxygenation on maximum ventilator support a few days postoperatively. Transfer to the operating room may be difficult or dangerous in these patients, and femoral cannulation with venovenous bypass has less associated morbidity than repeat central cannulation. A statement that venoarterial ECMO has superior results compared with venovenous ECMO (or vice versa) cannot be supported by comparing two different indications and two different pathologies.
It is encouraging to see other groups obtaining good results in this challenging patient population, and with appropriate experience, a mortality rate of less than 5% should be achieved in the current era of pulmonary endarterectomy, with return to normal function most patients.
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