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E. Mazzaro Dept. Of Cardiopulmonary Sciences University Hospital, Udine, Italy

SURGICAL TREATMENT FOR PULMONARY ARTERIAL HYPERTENSION: PULMONARY THROMBOENDOARTERECTOMY (PTE). E. Mazzaro Dept. Of Cardiopulmonary Sciences University Hospital, Udine, Italy. IPERTENSIONE ARTERIOSA POLMONARE Palmanova , June 13, 2009. PULMONARY THROMBOENDOARTERECTOMY HISTORY.

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E. Mazzaro Dept. Of Cardiopulmonary Sciences University Hospital, Udine, Italy

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  1. SURGICAL TREATMENT FOR PULMONARY ARTERIAL HYPERTENSION: PULMONARY THROMBOENDOARTERECTOMY (PTE) E. Mazzaro Dept. Of Cardiopulmonary Sciences University Hospital, Udine, Italy IPERTENSIONE ARTERIOSA POLMONARE Palmanova , June 13, 2009

  2. PULMONARY THROMBOENDOARTERECTOMY HISTORY MOSER,1970: FIRST SUCCESSFUL OPERATION USING CARDIOPULMONARY BYPASS. BRAUNWALD,1970: COMMENCED A PTE PROGRAM AT THE UNIVERSITY OF CALIFORNIA SAN DIEGO (UCSD). SABISTON, 1977: ANALYSIS OF 18 OPERATIONS REPORTED IN THE WORLD LITERATURE. CABROL 1978, DAILY 1980, DOR 1981, UTLEY 1982. CHITWOOD, 1984: WORLD LITERATURE REVIEWED (85 CASES, 22% MORTALITY). WINKLER, 1990: PERFUSION TECHNIQUE OF PROFOUND HYPOTERMIA AND CIRCULATORY ARREST FOR PTE. JAMIESON (UCSD), 2008: MORE THAN 2500 CASE.

  3. PULMONARY THROMBOENDOARTERECTOMY CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION – THERAPY THIS DISEASE, IF NOT TREATED, USUALLY EVOLVES TO HEART FAILURE AND EVENTUALLY TO DEATH. MEDICAL THERAPY HAS ONLY A PALLIATIVE ROLE. LUNG AND HEART-LUNG TRANSPLANTATION MIGHT BE A SOLUTION. HOWEVER THEY HAVE DIFFERENT DRAWBACKS (Donoravailability, Costs, immunosuppressive therapy, etc). PULMONARY THROMBOENDOARTERECTOMY HAS PROVED A VALUABLE AND SAFE ALTERNATIVE TO TRANSPLANTATION

  4. PULMONARY THROMBOENDOARTERECTOMY THREE MAJOR REASONS HEMODYNAMIC: PREVENT OR AMELIORATE RIGHT VENTRICULAR FUNCTION COMPROMISED BY PH . RESPIRATORY: IMPROVE RESPIRATORY FUNCTION BY REMOVAL OF A LARGE VENTILATED BUT UNPERFUSED PHYSIOLOGIC DEAD SPACE , REGARDLESS THE SEVERITY OF PH. PROPHYLACTIC: TO PREVENT PROGRESSIVE RIGHT VENTRICULAR DYSFUNCTION RETROGRADE EXTENSION OF OBSTRUCTION AND SECONDARY ARTERIOPATHIC CHANGES IN THE REMAINING PATENT VESSELS. OUTCOMES OF SURGERY VARY ACCORDING TO THE OPERATIVE CLASSIFICATION

  5. PULMONARY THROMBOENDOARTERECTOMY TYPICAL PATIENT UNDERGOING SURGERY NYHA CLASS III-IV SEVERELY ELEVETED PULMONARY VASCULAR RESISTANCE (PVR) LEVEL AT REST ABSENCE OF SIGNIFICANT COMORBID DISEASE NOT RELATED TO RIGHT HEART FAILURE APPEARANCE OF CHRONIC THROMBI ON ANGIOGRAM RELATIVELY IN BALANCE WITH THE MEASURED PVR LEVEL

  6. PULMONARY THROMBOENDOARTERECTOMY TYPICAL PATIENT UNDERGOING SURGERY MOST PATIENTS PRESENT PVR LEVEL IN THE RANGE OF 700-1000 DYNE*SEC*CM-5 AND LESS THAN SYSTEMIC PAP 20% OF PATIENTS PRESENT PVR LEVEL IN EXCESS OF 1000 DYNE*SEC*CM-5 AND SUPRASYSTEMIC PAP NO UPPER LIMIT OF PVR LEVEL AND PAP OR DEGREE OF RIGHT VENTRICULAR FUNCTION EXCLUDES PATIENTS FROM OPERATION

  7. PULMONARY THROMBOENDOARTERECTOMY University of California, San Diego Medical Center La Jolla, CA

  8. PULMONARY THROMBOENDOARTERECTOMY SURGICAL PRINCIPLES MEDIAN STERNOTOMY CARDIOPULMONARY BYPASS CIRCULATORY ARREST ENDOARTERECTOMY MUST BE BILATERAL ENDARTERECTOMY PLANE BETWEEN INTIMA AND MEDIA PLANE MUST BE FOLLOWED AND FREED UNTIL IT ENDS IN A “TAIL” OTHER CARDIAC PROCEDURES DURING REWARMING PERIOD

  9. PULMONARY THROMBOENDOARTERECTOMY CAVAL FILTER CAVAL FILTER (GREENFIELD FILTER) ROUTINELY PLACED BEFORE THE OPERATION

  10. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE AORTIC AND BICAVAL CANNULATON PULMONARY ARTERY VENT COOLING CORE TEMPERATURE 20 ° C LEFT VENTRICULAR VENT AORTIC CROSS-CLAMP MYOCARDIAL PROTECTION SNARING IVC - SVC

  11. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: SET-UP

  12. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE START FIRST WITH THE RIGHT PULMONARY ARTERY THEN THE LEFT. FULLY MOBILIZATION OF SVC AND RIGHT PULMONARY ARTERY WITH MODIFIED CEREBRAL RETRACTOR DO NOT ENTER THE PLEURAL SPACE

  13. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: RIGHT PULMONARY ARTERY (PA) INCISION OF THE RIGHT PULMONARY ARTERY EMBOLECTOMY (IN MOST PATIENTS NO OBVIOUS EMBOLIC MATERIAL) ENDARTERECTOMY(BETWEEN INTIMA AND MEDIA) WITH EVERSION TECHNIQUE AREA OF FULL THICKNESS NEXT TO INCISION FOR CLOSURE PERFECT VISIBILITY WITH DEEP HYPOTHERMIC CIRCULATORY ARREST (20 min. FOR EACH SIDE)

  14. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: INSTRUMENTS

  15. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: RIGHT PA PLANE FOLLOWED AND FREED UNTIL IT ENDS IN A “TAIL” A PERFORATION IN SUBSEGMENTAL BRANCHES BECOMES COMPLETELY INACCESSIBILE AND INVISIBILE LATER ARTERIOTOMY REPAIRED WITH A CONTINUOUS 6/0 POLYPROPYLENE SUTURE HEMOSTASIS CIRCULATION TEMPORARY RESTARTED

  16. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: RIGHT PA

  17. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: LEFT PA SAME PRINCIPLES AS FOR THE RIGHT PA ARTERIOTOMY FROM THE SITE OF VENT HOLE TO THE PERICARDIAL REFLECTION HEART WRAPPED AND RETRACTED USING A MESH-LIKE BASKET RETRACTOR REWARMING (90-120 min.) AND WEANING FROM CPB

  18. PULMONARY THROMBOENDOARTERECTOMY SURGICAL TECHNIQUE: LEFT PA

  19. PULMONARY THROMBOENDOARTERECTOMY ALTERNATIVE SURGICAL TECHNIQUES DOUBLE CLAMP TECHNIQUE MODERATE HYPOTHERMIA AND SHORT PERIOD OF CIRCULATORY ARREST WITHOUT THE NEED OF PROFOUND HYPOTHERMIA DOUBLE VENTING SIMULTANEOUS SELECTIVE ANTEGRADE CEREBRAL PERFUSION OCCLUSION OF THE BRONCHIAL ARTERIES WITH AN OCCLUSIVE BALLOON CATHETER INTO DESCENDING AORTA

  20. PULMONARY THROMBOENDOARTERECTOMY ALTERNATIVE SURGICAL TECHNIQUES OCCLUSIVE BALLOON CATHETER DOUBLE CLAMP TECHNIQUE DOUBLE VENT TECHNIQUE

  21. PULMONARY THROMBOENDOARTERECTOMY POSTOPERATIVE CARE • DEMANDING POSTOPERATIVE MANAGEMENT • MECHANICALLY VENTILATION FOR AT LEAST 24 HOURS • EXTUBATION ON THE FIRST POSTOPOPERATIVE DAY WHENEVER POSSIBLE • HIGHER TIDAL VOLUMES MINUTE VENTILATION THAN AFTER CONVENTIONAL CARDIAC SURGERY • MAINTEINED DIURESIS (PATIENT PREOPERATIVE WEIGHT WITHIN 24 HOURS) • MINIMIZE FLUID ADMINISTRATION • HEMATOCRIT LEVEL ABOVE 30% • POSTOPERATIVE VENOUS THROMBOSIS PROPHYLAXIS • INTERMITTENT PNEUMATIC COMPRESSION DEVICES • SUBCUTANEOUS HEPARIN ON THE EVENING OF SURGERY • ANTICOAGULATION WITH A TARGET INR OF 2,5 TO 3

  22. PULMONARY THROMBOENDOARTERECTOMY POSTOPERATIVE CARE: VENOUS THROMBOSIS PROPHYLAXIS

  23. PULMONARY THROMBOENDOARTERECTOMY COMPLICATIONS • PERSISTENT PULMONARY HYPERTENSION • SODIUM NITROPRUSSIDE, EPOPROSTENOL OR INHALED NO ARE GENERALLY NOT EFFECTIVE • MECHANICAL CIRCULATORY SUPPORT OR EXTRACORPOREAL MEMBRANE OXIGENATOR (ECMO) USE NOT APPROPRIATE • REPERFUSION INJURY: LOCALIZED AND “DRAMATIC” FORM OF PULMONARY EDEMA • CAREFUL MANAGEMENT OF VENTILATION • FLUID BALANCE (AGGRESSIVE DIURESIS OR ULTRAFILTRATION, HIGH HEMATOCRIT) • VENOVENOUS EXTRACORPOREAL LIFE SUPPORT (V-V ECLS) • MORTALITY 30 % (PULMONARY HEMORRHAGE) • DELIRIUM (CIRCULATORY ARREST TIME >55 min.) • PERICARDIAL EFFUSION • ATRIAL ARRHYTHMIAS IN 10 % OF PATIENTS

  24. PULMONARY THROMBOENDOARTERECTOMY OUTCOMES: OPERATIVE MORTALITY

  25. PULMONARY THROMBOENDOARTERECTOMY OUTCOMES 1

  26. PULMONARY THROMBOENDOARTERECTOMY UCSD OPERATIVE CLASSIFICATION PREOPERATIVE PULMONARY ANGIOGRAM PVR 768 DYNE*S*CM-5 POSTOPERATIVE PULMONARY ANGIOGRAM (10 DAYS AS) PVR 196 DYNE*S*CM-5

  27. PULMONARY THROMBOENDOARTERECTOMY UCSD OPERATIVE CLASSIFICATION

  28. PULMONARY THROMBOENDOARTERECTOMY UCSD OPERATIVE CLASSIFICATION TYPE I:FRESH (ACUTE) THROMBUS IN THE MAIN-LOBAR PULMONARY ARTERIES. TYPE II:INTIMAL THICKENING AND FIBROSIS WITH OR WITHOUT ORGANIZED THROMBUS PROXIMAL TO SEGMENTAL ARTERIES ONLY. TYPE III: FIBROSIS, INTIMAL WEBBING AND THICKENING WITH OR WITHOUT ORGANIZED THROMBUS WITHIN DISTAL SEGMENTAL ARTERIES ONLY. TYPE IV: MICROSCOPIC DISTAL ARTERIOLAR VASCULOPATHY WITHOUT VISIBLE THROMBOEMBOLIC DISEASE.

  29. PULMONARY THROMBOENDOARTERECTOMY OPERATIVE CLASSIFICATION: TYPE III and IV vs TYPE I and II MORE RESIDUAL TRICUSPID REGURGITATION HIGHER POSTOPERATIVE (PO) PULMONARY ARTERY SYSTOLIC PRESSURE GREATER PO PULMONARY VASCULAR RESISTANCE HIGHER PO MORTALITY LONGER INOTROPIC SUPPORT LONGER HOSPITAL STAYS

  30. PULMONARY THROMBOENDOARTERECTOMY OUTCOMES

  31. PULMONARY THROMBOENDOARTERECTOMY CONCLUSIONS IN ALMOST EVERY CASE, THROMBOEMBOLIC PUMONARY HYPERTENSION SHOULD BE CONSIDERED A BILATERAL DISEASE. PATIENTS WITH TYPE I AND II THROMBOEMBOLIC DISEASE HAVE THE MOST FAVORABLE HEMODYNAMIC RESULT. PATIENTS WITH TYPE III THROMBOEMBOLIC DISEASE HAVE A WORSE POSTOPERATIVE OUTCOME. PATIENTS WITH TYPE IV THROMBOEMBOLIC DISEASE DO NOT HAVE SURGICAL CORRECTABLE DISEASE.

  32. PULMONARY THROMBOENDOARTERECTOMY CONCLUSIONS PATIENT AGE , DEGREE OF PULMONARY HYPERTENSION, CIRCULATORY ARREST TIME ARE RISK FACTORS FOR EARLY MORBIDITY AND MORTALITY. PREOPERATIVE PVR > 1100 DYNE*S*CM-5 AND MEAN PAP > 50 MMHG: HIGHER OPERATIVE MORTALITY. FAILURE TO LOWER PULMONARY ARTERY PRESSURE IS MOST PREDICTIVE OF IN-HOSPITAL MORTALITY. PNEUMONIA AND GASTROINTESTINAL COMPLICATIONS ARE THE POSTOPERATIVE COMPLICATIONS MOST ASSOCIATED WITH PERIOPERATIVE DEATH.

  33. PULMONARY THROMBOENDOARTERECTOMY CONCLUSIONS THE THREE MOST IMPORTANT DETERMINANTS OF CARDIAC SURGICAL OUTCOMES (“ESPECIALLY PTE”) ARE: PATIENT SELECTION PATIENT SELECTION PATIENT SELECTION “A Heart Surgeon’s littleinstruction book”

  34. PULMONARY THROMBOENDOARTERECTOMY PREOPERATIVE IMAGING EVALUATION

  35. Don’t be afraid to do a new procedure, be prepared “A Heart Surgeon’s little instruction book”

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