Operation by benbenzhou

VIEWS: 15 PAGES: 12

									                                                                                                                                                    3/12/2011




                  Chronic Thromboembolic                                                                          Embolic pulmonary hypertension:
                  Pulmonary Hypertension                             Pulmonary Hypertension                       Incidence & Prevalence

                                                                     Surgical Options
Stuart W. Jamieson
Cardiothoracic Surgery                                           Primary pulmonary hypertension                      What is the incidence
University of California
San Diego                                                                                          Single lung          of pulmonary
                                                                 Transplantation                   Double lung       hypertension due to
                                                                                                   Heart - lung       thromboembolic
                                                                 Thromboembolic disease                                    disease?
                                                                 Endarterectomy




               Embolic pulmonary hypertension:                 Embolic pulmonary hypertension:                    Embolic pulmonary hypertension:
               Incidence & Prevalence                          Incidence & Prevalence                             Incidence & Prevalence
                 ♦ More prevalent than recognized              ♦ More prevalent than recognized
                   – USA: Estimated 630,00 acute symptomatic     – USA: Estimated 630,00 acute symptomatic
                     PE’s with 500,000 survivors (1983)            PE’s with 750,000 survivors (2011)
                   – About 5% risk of chronic pulmonary          – About 5% risk of chronic pulmonary
                     hypertension following an acute PE            hypertension following an acute PE
                   – Estimated 25,000 cases annually (USA)       – Estimated 35,000 cases annually (USA)             Under – recognized condition
                                                               ♦Other causes
                                                                  –Indwelling catheters, leads, coagulation
                                                                  abnormalities, secondary vasculopathy

                                                               ? Number of cases of asymptomatic PE

                                                                      ? >50,000 yearly in USA




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   Treatment                                        Pulmonary Endarterectomy   Important Concepts
♦Medical:
  –Limited and temporary
  –Cannot remove mechanical obstruction                                        No disease is “too distal” for
  –Only supportive, does not affect the prognosis                              surgery
  –Symptoms generally not improved,
  unless obstruction is relieved                                               (no such thing as “surgically
♦ Surgical:                                                                    inaccessible”)
  – Mainstay of treatment
                                                                               No degree of pulmonary
  – Pulmonary endarterectomy
                                                                               hypertension, PVR or RV
  – Transplantation inappropriate
                                                                               failure too severe for operation




                                                                                PTE Specimen
   Pulmonary Angiography
 - combined with right heart catheterization

       The key to Diagnosis
   - Most valuable is to match PVR with
   extent of disease seen on
   pulmonary angiogram.

   - PVR / angiographic discordance
   will predict likely result – does not
   contraindicate operation




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                                            PVR pre-op >1,200
Pulmonary angiogram   Pulmonary angiogram
                                            PVR post-op < 300




Pulmonary angiogram   Pulmonary angiogram




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  Operation                                                     The Surgery
                                                        Median sternotomy
Tends to be underestimated
                                                        Cardiopulmonary bypass

Significant learning curve                              Deep hypothermic circulatory arrest
                                                        (DHCA)
                   Bilateral                            Both pulmonary arteries are treated
Mandatory
                                                        Complete endarterectomy
                  Circulatory arrest
                                                         ASD repair and other procedures




    RV

                RA
                                       The head is wrapped in a circulating cold water cooling blanket in preparation for
                                                       Deep Hypothermic Circulatory Arrest (DHCA)




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                                                                      Classification of Operative
Assessment of the cooling                     Removing the specimen   Specimens:
jacket in 55 patients -                                               –TYPE I:
                                                                        •15 - 20% of cases, major vessel clot is present
                                                                        and readily visible upon opening of PA
Rectal temperature 20.8 + 1.5 oC                                      –TYPE II:
                                                                        •60% of cases, no major vessel thrombus,
                                                                        thickened intima with webs
Bladder temperature 19.8 + 1.1 oC                                     –TYPE III:
                                                                         •15 - 20%, very distal disease, confined to
                                                                         segmental and sub-segmental branches
Tympanic temperature 15.1 + 1.1     oC   **                           –TYPE IV:
                                                                         •No thromboembolic pulmonary hypertension,
    ** p < 0.0001                                                         inoperable, intrinsic small vessel disease.




             Type 1                                Type 1                         Type 1




                                                                         Type I
                                                                                                        Type 2




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  Type 1 – fresh clot                     Type 1 – old clot                       Type 1




                                                                         Type I
                                                                                           Type 2




         Type 1                             Type 1                     Type 1 - Calcification


                                                              Type 2
                                 Type I




Type I                  Type 2




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Type 1 - Calcification           Type 2                   Type 2




Segmental disease – Type 3   Segmental disease – Type 3      Type 3




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  Primary pulmonary hypertension
  (Type IV)                                          PPH - no distal occlusion          …..           Results
                                                                                                ♦ >2,600 cases at UCSD Medical
                                                                                                 Center

                                                                                 “Trousers”,
                                                                                                  – Mean age 51 (ranging from 8 to 88)
                                                                                  not “tails”
                                                                                                  – Slight male predominance
                                                                                                  – One third had at least one additional
                                                                                                  cardiac procedure (PFO, ASD, CABG, etc.)
                                                                                                  – Average operative procedure was 7 hours
                                                                                                  – Cardiopulmonary bypass 218 + 41 min
                                                                                                  –   Myocardial ischemia time 88 + 25 min
                                                                                                  –   Circulatory arrest time 36 + 12 min




       Results <18 yrs.                                  Results <18 yrs.                             Results
♦ 17 patients < 18 years                          ♦ 17 patients < 18 years
                                                                                                  1. Hemodynamic
   –   Range 8 to 18                                 –   Range 8 to 18

   –   Operated on between 1998 - 2010               –   Operated on between 1998 - 2010
   – 67% had underlying hypercoagulable                                                           2. Mortality
   state                                             INITIAL DIAGNOSIS:
   – Lupus anticoagulant (5)
   – Anticardiolipin antibody (4)                    PPH                  5                       3. Long term
   – Protein C deficiency (3)                        Atypical pneumonia   3
                                                     Asthma               2
   NOT seen: Antithrombin III, Factor V Leiden,
   Prothrombin gene defects




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                                                                                   Pre & Post-op hemodynamics
  Results         Pre & Post-op hemodynamics
                                                                                   - < 18 years
                   80                 77            50                 46            80
                                                                                                          81                  50                  46
                                                    40                                                                        40
1. Hemodynamic     60
                                           47       30
                                                                           28
                                                                                     60
                                                                                                             46               30
                                                                                                                                                       27
                   40                                                                40
                                                    20                                                                        20
                   20                               10                               20                                       10
                                                     0                                   0                                     0
                    0
2. Mortality              Sys PA (mm Hg)                   Mean PA (mm Hg)                      Sys PA (mm Hg)                      Mean PA (mm Hg)



                 1000
                                     893             6                     5.54   1000
                                                                                                          929                 6                        5.6
3. Long term                                         4   3.84                      800
                                                                                   600
                                                                                                                              5
                                                                                                                              4   3.8
                 500
                                        285          2                             400                      299               3
                                                                                                                              2
                                                                                   200                                        1
                    0                                0                               0                                        0
                        PVR (dynes/sec/cm-5)                C.O. (L/min)                     PVR (dynes/sec/cm-5)                       C.O. (L/min)
                                               Pre-op                                                               Pre-op
                                               Post-op                                                              Post-op




  Results                                                                                        Hemodynamic
                 Overall Mortality By Era
                                                                                    Complete resolution anticipated in
1. Hemodynamic                                                                       >90% of cases


2. Mortality                                                                             If pre-op PVR > 1,000

                                                                                     – complete resolution
3. Long term                                                                         anticipated if PVR
                                                                                     concordant with
                                                                                     angiographic appearances




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Mortality By Pre-op PVR              Mortality – Last Two Years                              Mortality – < 18 years old

                                   ♦ Total Number: 270 patients                             ♦ Total Number: 17 patients
                                   ♦ No Mortality for Isolated PTE                          ♦ No operative mortality
                                     – Excluding Combined Procedures                        ♦ 2 late deaths:
                                          • PTE/CABG
                                                                                             rethrombosis (1)
                                          • PTE/Valve
                                                                                             residual pulmonary hypertension
                                          • PTE/Valve/CABG
                                                                                              (PVR 3,720 to 1,311)
                                       – Excluding Sarcoma Patients

                                                                                            ♦ Survival at 5 years = 87.5%




   Results                             Long-term Outcome                                       Pulmonary Endarterectomy
                           •Encouraging ….
                                                                                                 (versus transplantation)
 1. Hemodynamic            •Long-term anticoagulation, IVC filter
                           •Most patients return to NYHA class I or II
                                                                                                   Low mortality rate
 2. Mortality              •Improved autoregulation in pulmonary vascular
                           bed                                                                      Elective surgery
 3. Long term              •Remodeling of right (thus left) side of the heart,                     Considered a cure
                           with improved function
                                                                                                     Coumadin only
                          •Archibald et. Al.: Long term outcome after pulmonary
                          thromboendarterectomy. Am J Resp Crit Care Med 1999; 160: 523-8




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                                   Pulmonary Endarterectomy


   Transplantation NEVER
appropriate for thromboembolic      EVERY patient whose
                                    etiology is thromboembolic
   pulmonary hypertension           is a surgical candidate




                                 Conclusion:                      Conclusion:
    Patient at 12,000 feet       Condition Under-recognized       Poor prognosis
                                         Patient at 12,000 feet           Patient at 12,000 feet




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Conclusion:                       Conclusion:                       Conclusion:
Ineffective medical therapy       Surgical therapy curative
         Patient at 12,000 feet            Patient at 12,000 feet



                                                                    Operation requires circulatory
                                                                    arrest, absolutely bloodless field,
                                                                    and careful cooling and
                                                                    rewarming techniques




    Thank you




    UCSD Cardiovascular Center




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