Elsevier

Cardiology Clinics

Volume 22, Issue 3, August 2004, Pages 467-478
Cardiology Clinics

Review article
Pulmonary thromboendarterectomy surgery

https://doi.org/10.1016/j.ccl.2004.04.009Get rights and content

Section snippets

Incidence and natural history of chronic thromboembolic pulmonary hypertension

The natural history of pulmonary embolism is generally total embolic resolution or resolution leaving minimal residua with restoration of a normal hemodynamic status [8]. For unknown reasons, however, embolic resolution is incomplete in a small subset of patients. If the acute emboli are not lysed in 1 to 2 weeks, the embolic material becomes attached to the pulmonary arterial wall at the main pulmonary artery, lobar, segmental, or subsegmental levels [9]. With time, the initial embolic

Clinical manifestations

Patients with CTEPH usually present with subtle or nonspecific symptoms such as exertional dyspnea and exercise intolerance. As the disease progresses, additional symptoms such as edema, chest pain, light-headedness, and syncope may develop. Nonspecific chest pains occur in approximately 50% of patients with more severe pulmonary hypertension. Hemoptysis can occur, as in all forms of pulmonary hypertension. Peripheral edema, early satiety, and epigastric or right upper quadrant fullness or pain

Diagnostic evaluation of chronic thromboembolic pulmonary hypertension

Pulmonary vascular disease should be considered in the differential diagnosis of unexplained dyspnea. The diagnostic evaluation serves three purposes: to establish the presence and severity of pulmonary hypertension, to determine its cause, and, if thromboembolic disease is present, to determine to what degree it will be surgically correctible.

Chest radiography is often unrevealing in the early stages of chronic thromboembolic pulmonary hypertension. As the disease progresses, several

Surgical selection

Although there were previous attempts, Allison et al [33] performed the first successful pulmonary thromboendarterectomy through a sternotomy using surface hypothermia in a patient with a 12-day history of pulmonary embolism, but only fresh clots were removed, and an endarterectomy was not performed. Since then, there have been many reports of the surgical treatment of chronic pulmonary thromboembolism (Table 1), but by far the greatest surgical experience in pulmonary endarterectomy has been

Guiding principles of the operation

There are several guiding principles for the operation. The operation must be bilateral because, for pulmonary hypertension to be a major factor, both pulmonary arteries are usually substantially involved. The only reasonable approach to both pulmonary arteries is through a median sternotomy. Historically, there were reports of unilateral operation, and occasionally this procedure is still performed through a thoracotomy [36]. The unilateral approach, however, ignores disease on the

Pulmonary endarterectomy: surgical technique

After a median sternotomy incision is made, the pericardium is incised longitudinally and attached to the wound edges. Typically the right heart is enlarged, with a tense right atrium and a variable degree of tricuspid regurgitation. There is usually severe right ventricular hypertrophy, and with critical degrees of obstruction the patient's condition may become unstable with manipulation of the heart. Anticoagulation is achieved with the use of beef-lung heparin sodium (400 units/kg,

Thromboembolic disease classification and prediction of surgical outcome

Recently, four major types of pulmonary occlusive disease, based on anatomy and location of thrombus and vessel wall pathology, have been described [26]. This intraoperative classification of disease allows the prediction of patient outcome after pulmonary endarterectomy [35], [41].

  • 1.

    Type 1 disease (approximately 30% of cases of thromboembolic pulmonary hypertension) (Fig. 1)–fresh thrombus in the main or lobar pulmonary arteries. In this situation, major vessel clot is present and visible on the

Results of pulmonary endarterectomy

Although pulmonary endarterectomy is now performed at several major cardiovascular centers throughout the world, the greatest experience with this operation has been at the UCSD, where the technique was pioneered and refined. More than 1600 pulmonary endarterectomies have been performed at the UCSD since 1970 [34], whereas the entire reported world's literature on this operation (exclusive of UCSD) is approximately 500 cases. Since 1990, when the surgical procedure was modified as described in

Summary

Pulmonary hypertension caused by chronic pulmonary embolism is underrecognized and carries a poor prognosis. Medical therapy for this condition is ineffective and only transiently improves symptoms. The only therapeutic alternative to pulmonary endarterectomy is lung transplantation. The advantages of pulmonary endarterectomy include a lower operative mortality, better long-term results with respect to survival and quality of life, and the avoidance of chronic immunosuppressive treatment and

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