Initial Outcomes of Simultaneous Pulmonary Thromboendarterectomy and Hemiarch Replacement
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0173
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michael Cain (1), T. Brett Reece (1), Jordan Hoffman (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michael Cain
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Jordan Hoffman
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective
Pulmonary thromboendarterectomy (PTE) is the curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). A subset of CTEPH patients present with concomitant cardiac and aortic pathology.
Deep hypothermic circulatory arrest (DHCA) is the standard cerebral protection strategy during PTE given the short intervals of circulatory arrest, and the benefit of a bloodless field. However, the risks posed by coagulopathy caused by DHCA, combined with the need for post-operative anticoagulation, limit the ability to address co-occurring aortic pathology simultaneously, and to our knowledge prior literature has only discussed staged intervention of concomitant aortic pathology. Moderate hypothermia with selective antegrade cerebral perfusion (SACP) has also been applied to PTE, however, the standard remains DHCA given the above and prior trials demonstrating similar outcomes between the two cooling strategies.
We present a series of patients where PTE was performed simultaneously to ascending and hemiarch repair using both DHCA and moderate hypothermia, with additional retrograde cerebral perfusion (RCP) for both groups.
Methods
Using our retrospective database, we reviewed PTE performed at our institution, and identified four patients who underwent PTE with ascending and hemiarch replacement. Patient presentation, operative, and post-operative course was reviewed.
Results
All four patients underwent bilateral PTE, with ascending and hemiarch replacement. Three of the four patients underwent additional cardiac procedures. All patients received RCP via the superior vena cava, with three of the four receiving moderate hypothermia. During circulatory arrest time, cerebral oxygenation was monitored in addition to intraoperative neuromonitoring. Aortic replacement was performed prior to PTE for all cases. One patient underwent two periods of circulatory arrest, with aortic repair during circulatory arrest period for the right PTE. Three of the four patients underwent three periods of circulatory arrest, with separate periods for right and left PTE, and aorta (median 6 min, IQR 6-6). All periods of PTE circulatory arrest did not exceed 22 minutes (median 19 min, IQR 14.75-19.5). Three of four patients were extubated within 24 hours. One patient had a prolonged intubation of 92 hours. All patients were started on low dose heparin infusion within 6 hours of surgery, with gradual up-titration. One patient had a prolonged hospital course due to an unrelated complication of colonic perforation due to diverticulitis the day prior to planned discharge. All patients were discharged at baseline neurologic status with home oxygen on therapeutic warfarin with appropriate follow-up.
Conclusion
Our initial experience demonstrates that simultaneous PTE and ascending and hemiarch replacement can be safely performed. Performing aortic repair has the added benefit of improving operative view, particularly of the right pulmonary artery, by removing the aneurysmal aorta prior to PTE. Applying RCP has the added benefit of additional cerebral protection under moderate hypothermia while maintaining a bloodless field. Careful consideration must be placed perioperatively on balancing adequate resuscitation and anticoagulation initiation with the risks of reperfusion injury and bleeding.
Pulmonary thromboendarterectomy (PTE) is the curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). A subset of CTEPH patients present with concomitant cardiac and aortic pathology.
Deep hypothermic circulatory arrest (DHCA) is the standard cerebral protection strategy during PTE given the short intervals of circulatory arrest, and the benefit of a bloodless field. However, the risks posed by coagulopathy caused by DHCA, combined with the need for post-operative anticoagulation, limit the ability to address co-occurring aortic pathology simultaneously, and to our knowledge prior literature has only discussed staged intervention of concomitant aortic pathology. Moderate hypothermia with selective antegrade cerebral perfusion (SACP) has also been applied to PTE, however, the standard remains DHCA given the above and prior trials demonstrating similar outcomes between the two cooling strategies.
We present a series of patients where PTE was performed simultaneously to ascending and hemiarch repair using both DHCA and moderate hypothermia, with additional retrograde cerebral perfusion (RCP) for both groups.
Methods
Using our retrospective database, we reviewed PTE performed at our institution, and identified four patients who underwent PTE with ascending and hemiarch replacement. Patient presentation, operative, and post-operative course was reviewed.
Results
All four patients underwent bilateral PTE, with ascending and hemiarch replacement. Three of the four patients underwent additional cardiac procedures. All patients received RCP via the superior vena cava, with three of the four receiving moderate hypothermia. During circulatory arrest time, cerebral oxygenation was monitored in addition to intraoperative neuromonitoring. Aortic replacement was performed prior to PTE for all cases. One patient underwent two periods of circulatory arrest, with aortic repair during circulatory arrest period for the right PTE. Three of the four patients underwent three periods of circulatory arrest, with separate periods for right and left PTE, and aorta (median 6 min, IQR 6-6). All periods of PTE circulatory arrest did not exceed 22 minutes (median 19 min, IQR 14.75-19.5). Three of four patients were extubated within 24 hours. One patient had a prolonged intubation of 92 hours. All patients were started on low dose heparin infusion within 6 hours of surgery, with gradual up-titration. One patient had a prolonged hospital course due to an unrelated complication of colonic perforation due to diverticulitis the day prior to planned discharge. All patients were discharged at baseline neurologic status with home oxygen on therapeutic warfarin with appropriate follow-up.
Conclusion
Our initial experience demonstrates that simultaneous PTE and ascending and hemiarch replacement can be safely performed. Performing aortic repair has the added benefit of improving operative view, particularly of the right pulmonary artery, by removing the aneurysmal aorta prior to PTE. Applying RCP has the added benefit of additional cerebral protection under moderate hypothermia while maintaining a bloodless field. Careful consideration must be placed perioperatively on balancing adequate resuscitation and anticoagulation initiation with the risks of reperfusion injury and bleeding.
Aortic Symposium:
Aortic Arch
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