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Ann Thorac Surg 2009;88:649-650. doi:10.1016/j.athoracsur.2008.12.066
© 2009 The Society of Thoracic Surgeons
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Case Reports

Extracorporeal Life Support for the Control of Life-Threatening Pulmonary Hemorrhage

Victor Pretorius, MD, Walid Alayadhi, MD, Dennis Modry, MD*

Division of Cardiac Surgery, University of Alberta, Edmonton, Canada

Accepted for publication December 18, 2008.

* Address correspondence to Dr Modry, Division of Cardiac Surgery, University of Alberta Hospital, 3H2.10 WC Mackenzie Health Sciences Center, 8440 112 St, Edmonton, Alberta, T6G 2B7, Canada (Email: alayadhi{at}ualberta.ca).


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Pulmonary hemorrhage is a dreadful complication after pulmonary thromboendarterectomy. We describe a novel management in which the patient is supported with active venting of the pulmonary vascular bed while on veno-arterial extracorporeal life support.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Pulmonary thromboendarterectomy is a potentially curative procedure for chronic thromboembolic pulmonary hypertension. This procedure requires deep hypothermic circulator arrest and is technically demanding. Modern day operative mortality ranges from 4.8% to 15% [1]. Life-threatening pulmonary hemorrhage is a reported complication after this procedure [2].

Initial management for massive pulmonary hemorrhage includes bronchial blocker placement and correction of coagulopathy that is often present after deep hypothermic circulatory arrest. Placement of a bronchial blocker can result in hypoxemic respiratory failure necessitating institution of extracorporeal life support (ECLS), which invariably requires a state of anticoagulation.

We report the case of a 44-year-old Caucasian woman who presented with dysfunctional uterine bleeding. A careful history revealed the presence of progressive shortness of breath for a 6-month period.

On physical examination, an enlarged uterus was found. She had room air oxygen saturation of 80%.

A right heart catheterization revealed elevated pulmonary artery pressure of 90/28 mm Hg (mean, 53 mm Hg) that did not vary much with nitric oxide or nitroglycerine administration. Her echocardiogram revealed a dilated right ventricle with reduced systolic function and severe tricuspid regurgitation, but normal left ventricular function. Her arterial blood gas analysis demonstrated a PaO2 of only 57 mm Hg on room air. Spiral computed tomographic scanning of her chest showed web-like filling defects in her pulmonary vasculature on the right and left side consistent with chronic thromboembolic disease.

Pelvic ultrasonography demonstrated large uterine leiomyomatosis with compression on pelvic veins resulting in deep vein thrombosis. Extensive blood workup was negative for hypercoagulable states.

Ventilation perfusion scanning and cardiac magnetic resonance imaging confirmed the diagnosis of Jamieson type III chronic thromboembolic pulmonary hypertension [1].

The patient underwent standard workup for pulmonary thromboendarterectomy and lung transplantation as a backup plan. She was anticoagulated with warfarin and a Greenfield filter (Medtronic Inc, Minneapolis, MN) was inserted to prevent further pulmonary embolism.

She continued to be severely symptomatic with shortness of breath and a decision was made to proceed with pulmonary thromboendarterectomy.

A standard pulmonary thromboendarterectomy was performed by dissecting in the medial layer of the main pulmonary arterial tree to the subsegmental level where the web-like obstructions were located. The procedure was technically very demanding due to friable tissues and required a total of 138 minutes of deep hypothermic circulatory arrest.

Weaning from cardiopulmonary bypass was unsuccessful secondary to persistent pulmonary hypertension and right ventricular failure. Frank massive pulmonary hemorrhage also developed in her right lung requiring bronchial blocker placement. This resulted in an inability to adequately ventilate her leading to severe hypoxemia. A surgical injury at an inaccessible area was suspected.

A decision was made to support the patient with ECLS and to list her for urgent double lung or heart double lung transplantation. In an attempt to offload her pulmonary vasculature, bi-caval cannulation with snares was established with the addition of two 14 French Argyl vent cannulas (Medtronic Inc, Minneapolis, MN) inserted into the pulmonary artery and the left atrium (through the right superior pulmonary vein) and then Y-shaped into the ECLS circuit (Fig 1).


Figure 1
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  		Fig 1. Extracorporeal life support circuit with active venting of pulmonary vascular bed. (Ao = aorta; IVC = inferior vena cava; LA = left atrium; PA pulmonary artery; RA = right atrium; RSPV = right superior pulmonary vein; RV = right ventricle; SCV = superior vena cava.)

 
She was supported in the intensive care unit for a period of 4 days on ECLS. During this time the pulmonary hemorrhage subsided, allowing deflation of the bronchial blocker after 12 hours on ECLS and ventilation of the right lung. She further tolerated gradual diuresis. To our surprise, her right ventricular function improved and her pulmonary arterial hypertension also improved to a point at which she was successfully weaned from ECLS. Despite a further setback with an intracranial hemorrhage from which she made a full and complete recovery, she also made a dramatic cardiorespiratory recovery to a point at which she was in New York Heart Association functional class I at 6 weeks after her surgery. She successfully returned to be the caregiver of her family without any limitations.


   Comment
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 Abstract
 Introduction
 Comment
References
 
Pulmonary thromboendarterectomy is the procedure of preference for patients with chronic thromboembolic pulmonary hypertension with the potential for a complete cure in many. To perform the procedure with consistent and predictable results deep hypothermic circulatory arrest is recommended by leaders in the field [3]. The surgery is technically demanding and has the potential for complications, such as massive pulmonary hemorrhage. Pulmonary hemorrhage can result from reperfusion injury in which capillary permeability is increased after re-establishment of blood flow to lung segments previously occluded by organized thrombus. Surgical trauma bridging the pulmonary artery adventitia during dissection of the endarterectomy specimen can also result in massive pulmonary hemorrhage and was suspected as the cause in our patient. All efforts should be made to avoid this often fatal complication by careful and detailed dissection, but also by maintaining a state of relative hyperosmolality with Mannitol administration and by stabilizing capillary permeability with corticosteroid administration. Veno-veno ECLS is well described for the management of reperfusion pulmonary edema [4]. In our case, support for both blood oxygenation and cardiac pump function was required. By instituting veno-arterial ECLS with active venting of the pulmonary artery and the left atrium, we were able to completely offload the pulmonary vasculature. Support in this fashion allowed for repair of the pulmonary arterial injury, presumably by strengthening of the fibrin clot with time under low pressure conditions, as well as a gradual lowering in the pulmonary vascular resistance and improvement in right and left ventricular diastolic dysfunction. Gradual diuresis allowed for lower lung water content and improved ventilation.

This surprising outcome allowed us to avoid lung transplantation and afforded the patient to make a full and complete recovery.

We conclude that a multidisciplinary team approach should be in place for the management of massive pulmonary hemorrhage, as a potential complication after pulmonary thromboendarterectomy. We would recommend complete venting of the pulmonary vascular bed in the event of massive pulmonary hemorrhage based on our experience with this case.


   References
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 Abstract
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 References
 

  1. Jamieson SW, Kapelanski DP, Sakakibara N, et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases Ann Thor Surg 2003;76:1457-1462.[Abstract/Free Full Text]
  2. Manecke GR, Kotzur A, Atkins G, et al. Massive pulmonary hemorrhage after pulmonary thromboendarterectomy Anesth Analg 2004;99:672-675.[Abstract/Free Full Text]
  3. Jamieson SW. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: is deep hypothermia required? Eur J Cardio-Thorac Surg 2006;30:241-243.[Free Full Text]
  4. Thistlethwaite PA, Madani MM, Kemp AD, et al. Venovenous extracorporeal life support after pulmonary endarterectomy: indications, techniques, and outcomes Ann Thorac Surg 2006;82:2139-2146.[Abstract/Free Full Text]




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