Technical Advances of Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension
Section snippets
Technical Principles of the Procedure
There are several guiding principles for this operation. First and foremost the approach must be bilateral, because, for pulmonary hypertension to be a major factor, both pulmonary arteries must be substantially involved. Furthermore, it is extremely unlikely to have unilateral disease as the result of thromboembolism. In fact we believe that a small subgroup of our patients, who truly do have unilateral disease, perhaps suffer from an underlying pulmonary vascular pathologic problem with
Preoperative and Anesthetic Considerations
Much of the preoperative preparation is common to any open-heart procedure. Routine monitoring for anesthetic induction includes a surface electrocardiogram, cutaneous oximetry, and radial artery pressures. After anesthetic induction a pulmonary artery catheter is placed for monitoring of pulmonary pressures as well as pulmonary vascular calculations. A femoral artery catheter, in addition to a radial arterial line, is also placed at this time. This provides more accurate measurements during
Surgical Technique
The surgical approach for this procedure is through a median sternotomy to gain access to both sides. The median sternotomy should be performed with extra attention given to all the engorged and collateral venous circulation that could develop as a result of persistent high right atrial pressures. After a median sternotomy incision is made, the pericardium is incised longitudinally and attached to the wound edges. Typically the right heart is severely enlarged, with a tense right atrium and a
Conclusions
It is increasingly apparent that pulmonary hypertension caused by chronic pulmonary embolism is a condition which is under-recognized and carries a poor prognosis. Because of the obstructive nature of this disease, medical therapy remains ineffective in prolonging life and at best only transiently improves the symptoms. The only therapeutic alternative to pulmonary endarterectomy is lung transplantation. The advantages of thromboendarterectomy include a lower operative mortality and excellent
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