[Surgical aspects of pulmonary thrombendarterectomy]

Pulmonary thromboendarterectomy is an accepted operative procedure for treatment of pulmonary hypertension due to chronic embolism. Despite its proven value this procedure has been established at very few centers worldwide. In this paper we report our actual operative concept and operative results. Between 8'89 and 4'96 127 patients were operated with use of extracorporeal circulation, deep hypothermia and circulatory arrest. After analysis of the initial high perioperative mortality (26%, 29/108) our operative and postoperative concept changed since 11'94: 1. central incision of both pulmonary arteries, 2. endarterectomy exclusively during circulatory arrest, 3. prolonged reperfusion to 37 degrees C, 4. pressure controlled ventilation, NO-inhalation, early extubation, and 5. modified vasopressor therapy. Preoperatively 12 of the 19 patients were in NYHA class III and 6 in class IV. Mean pulmonary artery pressure was 52(17) mmHg with a calculated pulmonary resistance of 1013(579) dynes.s.cm-5. Mean circulatory arrest time was 37 min (19-57 min) (bypass time 345 min, (240-430 min)). Perioperatively two patients (11%) died (multiorgan failure; rethrombosis of pulmonary artery/right heart failure), all other patients survived (89%). Perioperative complications included reversible renal failure, delirium and postcardiotomy syndrome (1/2/1). Mean pulmonary resistance was postoperatively significantly reduced (362(124) dynes.s.cm-5) (p < 0.01). Early results of pulmonary thromboendarterectomy can be improved by consequent modifications of the intra- and postoperative concept.