Abstract
For the treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH) with combined damage to the pulmonary vessels, thromboendarterectomy (EAE) is increasingly used with the partial use of deep hypothermic circulatory arrest (HCA) or without stopping cardiopulmonary bypass (CB) at all, including on a contracting heart in normothermia.
The aim of the study: To analyze and evaluate the results of surgical treatment of chronic thromboembolic pulmonary hypertension in the setting of cardiopulmonary bypass, moderate hypothermia, cardioplegia, and without the use of hypothermic circulatory arrest.
Material and methods. A retrospective analysis of the performance of open thromboendarterectomy in 70 patients operated on from January 2018 to February 2023 in the setting of coronary bypass (CB), hypothermia, cardioplegia, and without the use of HCA was presented. Immediate outcomes were analysed in the form of clinical examination, transthoracic echocardiography, computed tomography (CT) and heart catheterization (HC).
Results. The obtained data were analyzed in all patients before surgery, as well as in the postoperative period. The mean age of the patients was 48.1 ± 10.5 years, 46% male and 54% female. At the preoperative examination, 55 (78.6%) patients were assigned to NYHA FC III and 15 (21.4%) to NYHA IV FC. Nature and structure of blood clots according to classification Jamieson SW were type I in 42 (60%) patients and type II in 28 (40%) patients. None of the patients had type III or IV. Postoperative pulmonary artery systolic pressure (PASP) decreased from 84.5 ± 17 to 42.3 ± 12.2 mmHg, and mean (mPAP) from 51.1 ± 11.2 to 36.3 ± 9.0 mmHg. Four patients died, the in-hospital mortality rate was 5.7%. The mean CB time was 169 ± 57.5 minutes, the aortic cross clamp time was 82.9 ± 25.2 minutes, and the mean temperature during bypass ranged from 28 to 34 degrees. In one case, the cause of death was edema and wedging of the brain stem against the background of severe heart failure (HF), in the remaining 3 cases, the progression of cardiopulmonary insufficiency was due to a pronounced reperfusion syndrome. None of the cases were identified specific neurological complications typical of HCA surgery. In all patients, blood gas exchange indices improved with an increase in saturation from 90.1 ± 1.8% to 96.6 ± 1.7%, and the clinical condition improved, amounting to NYHA FC I in 48 (68%) patients, II in 15 (21%) patients, and III in 3 (4.2%) patients. Postoperative echocardiography revealed an improvement in the function of the right ventricle (RV) and a decrease of tricuspid valve (TC) insufficiency, and on CT examination with contrast, the adequacy of the surgery performed.
Conclusion. Pulmonary endarterectomy performed in the setting of CB and without circulatory arrest can have good immediate results in the form of improvement of the clinical condition and parameters of hemodynamics of the pulmonary circulation. When deciding whether to use this technique, it is necessary to take into account the volume and location of thrombotic masses.
References
- Riedel M., Stanek V., Widimsky J., Perovsky I. Long term follow-up of patients with pulmonary thromboembolism. Late prognosis and evolution of hemodynamic and respiratory data. Chest. 1982; 81: 151–158.
- Lewczuk J., Pizko P., Jagas J., Porada A., Wójciak S., Sobkowicz B., Wrabec K. Prognostic factors in medically treated patients with chronic pulmonary embolism. Chest. 2001; 119: 818–823.
- Pengo V., Lensing A.W., Prins M.H., Marchiori A., Davidson B.L., Tiozzo F. et al. For the Thromboembolic Pulmonary Hypertension Study Group. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N. Engl. J. Med. 2004; 350: 2257–2264.
- Moser K.M., Auger W.R., Fedullo P.F. Chronic major-vessel thromboembolic pulmonary hypertension. Circulation. 1990; 81: 1735–1743. DOI: 10.1161/01.cir.81.6.1735
- Mahmud E., Madani M.M., Kim N.H., Poch D., Ang L., Behnamfar O. et al. Chronic thromboembolic pulmonary hypertension: evolving therapeutic approaches for operable and inoperable disease. J. Am. Coll. Cardiol. 2018; 71: 2468–2486. DOI: 10.1177/20458940211007385
- Moser K.M., Daily P.O., Peterson K., Dembitsky W., Vapnek J.M., Shure D. et al. Thromboendarterectomy for chronic, major-vessel thromboembolic pulmonary hypertension. immediate and long-term results in 42 patients. Ann. Intern. Med. 1987; 107: 560–565. DOI: 10.7326/0003-4819-107-4-560
- Pepke-Zaba J., Delcroix M., Lang I., Mayer E., Jansa P., Ambroz D. et al. Chronic thromboembolic pulmonary hypertension (CTEPH): results from an International Prospective Registry. Circulation. 2011; 124: 1973–1981. DOI: 10.1161/CIRCULATIONAHA.110.015008
- Bisoi A.K., Ramakrishnan P., Chauhan S., Sahu M.K., Chandrasekharan N.C. An experience on normothermic beating heart pulmonary thromboendarterectomy. World J. Cardiovasc. Surg. 2019; 9 (1): 1–13. DOI: 10.4236/wjcs.2019.91001
- Delcroix M., Torbicki A., Gopalan D., Sitbon O., Klok F.A., Lang I. et al. ERS Statement on Chronic Thromboembolic Pulmonary Hypertension. Eur. Respir. J. 2021; 57: 2002828.
- Humbert M., Kovacs G., Hoeper M.M., Badagliacca R., Berger R.M., Brida M. et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: Developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). Eur. Heart J. 2022; 43 (38): 3618–3731. DOI: 10.1093/eurheartj/ ehac237
- Chazova I.E., Martynyuk T.V., Valieva Z.S., Azizov V.A., Akchurin R.S., Ansheles A.A. et al. Eurasian Guidelines for the diagnosis and treatment of chronic thromboembolic pulmonary hypertension (2020). Eurasian Heart Journal. 2021; 1: 6–43 (in Russ.). DOI: 10.38109/2225-1685-2021-1-6-43
- Kenneth M., Pat O.D., Kirk P., Moser K.M., Daily P.O., Peterson K. et al. Thromboendarterectomy for chronic, major-vessel thromboembolic pulmonary hypertension: immediate and long-term results in 42 patients. Ann. Intern. Med. 1987; 107: 560–564. DOI: 10.7326/0003-4819-107-4-560
- Madani M.M. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: state-of-the-art 2020. Pulm. Circulation. 2021; 11 (2): 1–6. DOI: 10.1177/20458940211007372
- Faccioli E., Verzeletti V., Marra M.P., Boscolo A., Schiavon M., Navalesi P. et al. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: a systematic review of the most updated literature. J. Clin. Med. 2022; 11: 6976. DOI: 10.3390/jcm11236976
- Kamenskaya O.V., Cherniavsky A.M., Klinkova A.S., Cherniavsky M.A., Meshkov I.O., Lomivorotov V.V. et al. Efficiency of various cerebral protection techniques used during the surgical treatment of chronic pulmonary thromboembolism. J. Extra Corpor. Technol. 2015; 47 (2): 95–102.
- Tian D.H., Wan B., Bannon P.G., Misfeld M., LeMaire S.A., Kazui T. et al. A meta-analysis of deep hypothermic circulatory arrest versus moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion. Ann. Cardiothorac. Surg. 2013; 2 (2): 148–158. DOI: 10.3978/j.issn.2225- 319X.2013.03.13
- Fisk G.C., Wright J.S., Hicks R.G., Anderson R.M., Turner B.B., Baker W.C. et al. The influence of duration of circulatory arrest at 20 degrees C on cerebral changes. Anaesth. Intens. Care. 1976; 4: 126–134.
- Yu L., Gu T., Zhang G., Cheng S., Fang Q., Mao N. The deep hypothermic circulatory arrest causes more kidney malfunctions based on a novel rabbit model. Ann. Saudi Med. 2014; 34 (6): 532–540. DOI: 10.5144/0256-4947.2014.532
- Zhang C., Wang G., Zhou H., Lei G., Yang L., Fang Z. et al. Preoperative platelet count, preoperative hemoglobin concentration and deep hypothermic circulatory arrest duration are risk factors for acute kidney injury after pulmonary endarterectomy: a retrospective cohort study. J. Cardiothorac. Surg. 2019; 14 (1): 220.
- Mazzeffi M., Marotta M., Lin H.M., Fischer G. Duration of deep hypothermia during aortic surgery and the risk of perioperative blood transfusion. Ann. Card. Anaesth. 2012; 15 (4): 266–273.
- Mikus P.M., Dell’Amore A., Pastore S., Galie N. How-to-do-it. Pulmonary endarterectomy: is there an alternative to profound hypothermia with cardiocirculatory arrest? Eur. J. Cardiothorac. Surg. 2006; 30: 563–565. DOI: 10.1016/j.ejcts.2006.06.016
- Thomson B., Tsui Steven S.L., Dunning J., Goodwin A., Vuylsteke A., Latimer R. et al. Pulmonary endarterectomy is possible and effective without the use of complete circulatory arrest – the UK experience in over 150 patients. Eur. J. Cardiothorac. Surg. 2008; 33: 157–163. DOI: 10.1016/j. ejcts.2007.11.009
- Hagl C., Khaladj N., Peters T., Hoeper M.M., Logemann F., Haverich A., Macchiarini P. Technical advances of pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Eur. J. Cardiothorac. Surg. 2003; 23: 776–781. DOI: 10.1016/S1010-7940(03)00029-0
- Lafci G., Tasoglu I., Ulas M.M., Yalcinkaya A., Cagli K. Pulmonary endarterectomy: with use of moderate hypothermia and antegrade cerebral perfusion without circulatory arrest. Tex. Heart Inst. J. 2012; 39 (1): 65–67.
- Masuda M., Mogi K., Nakaya M., Pearce Y., Imamaki M., Shimura H. et al. Surgical treatment for chronic pulmonary thromboembolism under cardiopulmonary bypass with selective cerebral perfusion. Surg. Today. 2001; 31 (2): 108–112.
- Kynta R.L., Rawat S., Mandal M., Saikia M.K. Pulmonary thromboendarterectomy without circulatory arrest. Braz. J. Cardiovasc. Surg. 2022; 37 (3): 394–400. DOI: 10.21470/1678-9741-2020-0534
- Galie N., Humbert M., Vachiery J.L., Gibbs S., Lang I., Torbicki A. et al. 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: the joint task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). Eur. Heart J. 2016; 37: 67–119.
- Jamieson S.W., Kapelanski D.P., Sakakibara N., Manecke G.R., Thistlethwaite P.A., Kerr K.M. et al. Pulmonary endarterectomy: experience and lessons learned in 1,500 cases. Ann. Thorac. Surg. 2003; 76 (5): 1457–1462; discussion 1462–1464. DOI: 10.1016/s00034975(03)00828-2
- Cannon J.E., Su L., Kiely D.G., Page K., Toshner M., Swietli E. et al. Dynamic risk stratification of patient long‐term outcome after pulmonary endarterectomy: results from the United Kingdom National Cohort. Circulation. 2016; 133: 1761–1771. DOI: 10.1161/ CIRCULATIONAHA.115.019470
- Sakurai Y., Takami Y., Amano K., Higuchi Y., Akita K., Noda M. et al. Predictors of outcomes after surgery for chronic thromboembolic pulmonary hypertension. Ann. Thorac. Surg. 2019; 108 (4): 1154–1161. DOI: 10.1016/j.athoracsur.2019.03.100
- Jamieson S.W. Historical perspective: surgery for chronic thromboembolic disease. Semin. Thorac. Cardiovasc. Surg. 2006; 18 (3): 218–222. DOI: 10.1053/j.semtcvs.2006.09.007
- Mayer E., Klepetko W. Techniques and outcomes of pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Proceed. Am. Thorac. Society. 2006; 3: 589–593.
- Ergin M.A., Galla J.D., Lansman S.L., Quintana C., Bodian C., Griepp R.B. Hypothermic circulatory arrest in operations on the thoracic aorta. Determinants of Operative Mortality and Neurologic Outcome. J. Surg. 1994; 107: 788–797.
- Ergin M.A., Griepp E.B., Lansman S.L., Galla Ja.D., Levy M., Griepp R.B. et al. Hypothermic Circulatory Arrest and Other Methods of Cerebral Protection during Operations on the Thoracic Aorta. J. Cardiac. Surg. 1994; 9: 525–537. DOI: 10.1111/j.1540-8191.1994.tb00886.x
- Guth S., D’Armini A.M., Delcroix M., Nakayama K., Fadel E., Hoole S.P. et al. Current strategies for managing chronic thromboembolic pulmonary hypertension: results of the worldwide prospective CTEPH Registry. ERJ Open Res. 2021; 7: 00850–2020. DOI: 10.1183/23120541.00850-2020
- Mayer E., Jenkins D., Lindner J., D’Armini A., Kloek J., Meyns B. et al. Surgical management and outcome of patients with chronic thromboembolicpulmonary hypertension: results from an International Prospective Registry. J. Thorac. Cardiovasc. Surg. 2011; 141: 702–710. DOI: 10.1016/j. jtcvs.2010.11.024
- Miyahara S., Schröder T.A., Wilkens H., Karliova I., Langer F., Kunihara, T., Schäfers H.-J. Long-term outcomes after pulmonary endarterectomy in 499 patients over a 20-year period. Ann. Thorac. Surg. 2021; 111: 1585–1592.
- Sihag S., Le B., Rodriguez-Lopez J.M., Villavicencio M.A. Vlahakes G.J. et al. Quantifying the learning curve for pulmonary thromboendarterectomy. J. Cardiothorac. Surg. 2017; 12: 121.
- Hsieh W.C., Jansa P., Huang W.C., Nižnanský M., Omara M., Lindner J. Residual pulmonary hypertension after pulmonary endarterectomy: a meta‐analysis. J. Thorac. Cardiovasc. Surg. 2018; 156: 1275–1287. DOI: 10.1016/j.jtcvs.2018.04.110
- Korsholm K., Andersen A., Mellemkjær S., Nielsen D.V., Klaaborg K.E., Ilkjær L.B., Nielsen-Kudsk J.E. Results from more than 20years of surgical pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension in Denmark. Eur. J. Cardiothorac. Surg. 2017; 52: 704–709.
- Quadery S.R., Swift A.J., Billings C.G., Thompson A.A.R., Elliot C.A., Hurdman J. et al. The Impact of patient choice on survival in chronic thromboembolic pulmonary hypertension. Eur. Respir. J. 2018; 52: 1800589.
- Hartz R.S., Byrne J.G., Levitsky S., Park J., Rich S. Predictors of mortality in pulmonary thromboendarterectomy. Ann. Thorac. Surg. 1996; 62: 1255–1260.
- Freed D.H., Thomson B.M., Berman M., Tsui S.S.L., Dunning J., Sheares K.K. et al. Survival after pulmonary thromboendarterectomy: effect of residual pulmonary hypertension. J. Thorac. Cardiovasc. Surg. 2011; 141: 383–387.
- Madani M.M., Auger W.R., Pretorius V., Sakakibara N., Kerr K.M. et al. Pulmonary endarterectomy: recent changes in a single institution’s experience of more than 2700 patients. Ann. Thorac. Surg. 2012; 94: 97–103, discussion 103.
- Saouti N., de Man F., Westerhof N., Boonstra A., Twisk J., Postmus P.E., Vonk Noordegraaf A. Predictors of mortality in inoperable chronic thromboembolic pulmonary hypertension. Respir. Med. 2009; 103: 1013–1019.
- Kallonen J., Korsholm K., Bredin F., Corbascio M., Andersen M.J., Ilkjær L.B. et al. Association of residual pulmonary hypertension with survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Pulm. Circ. 2022; 12: e12093. DOI: 10.1002/pul2.12093
- Thistlethwaite P.A., Mo M., Madani M.M., Deutsch R., Blanchard D., Kapelanski D.P., Jamieson S.W. Operative calssification of thromboembolic disease determines outcome after pulmonary endarterectomy. J. Thorac. Cardiovasc. Surg. 2002; 124: 1203–1211.
About the authors
- Sergey V. Gorbachevsky, Dr. Med. Sci., Professor, Chief Researcher; ORCID
- Tatyana B. Averina, Cand. Med. Sci., Chief of the perfusion department; ORCID
- Komoliddin Kh. Rakhmonov, Cand. Med. Sci., Cardiovascular Surgeon; ORCID
- Maria Yu. Khalvani, Cardiovascular Surgeon; ORCID
- Ruslan A. Aybazov, Junior Researcher; ORCID
- Elena A. Andreeva, Cand. Med. Sci., Anesthesiologist and Resuscitator; ORCID
- Amirulo A. Sabitov, Cardiovascular Surgeon; ORCID
