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CARDIOVASCULAR ANESTHESIA

Pulmonary Artery Thromboendarterectomy: A Comparison of Two Different Postoperative Treatment Strategies

Peter Mares, MD^*, Timothy B. Gilbert, MD^||, Edda M. Tschernko, MD^*, Michael Hiesmayr, MD^*, Manfred Muhm, MD^*, Andreas Herneth, MD, Sharoukh Taghavi, MD, Walter Klepetko, MD, Irene Lang, MD^§, and Wolfram Haider, MD^*

Departments *Cardiothoracic Anesthesia and Intensive Care, Radiology, Cardiothoracic Surgery, and §Cardiology, University of Vienna, Vienna, Austria; and ||Department of Cardiothoracic Anesthesia, University of Maryland, Baltimore, Maryland

Address correspondence and reprint requests to Peter Mares, MD, Department of Cardiothoracic Anesthesia and Intensive Care, Vienna General Hospital, University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.

Pulmonary artery thromboendarterectomy (PTE) is a potentially curative surgical procedure for chronic thromboembolic pulmonary hypertension. It is, nevertheless, associated with considerable mortality caused by postoperative complications, such as reperfusion pulmonary edema (RPE) (i.e., pulmonary infiltrates in regions distal to vessels subjected to endarterectomy) and right heart failure (RHF). However, there are no reports about the influence of different postoperative treatment strategies on complications and mortality. Therefore, we compared two different treatment strategies. In Group I (n = 33), positive inotropic catecholamines and vasodilators were avoided during termination of cardiopulmonary bypass (CPB) and thereafter, and mechanical ventilation was performed with low tidal volumes < 8 mL/kg, duration of inspiration:duration of expiration = 3:1, and peak inspiratory pressures < 18 cm H₂O. In Group II (n = 14), positive inotropic catecholamines and vasodilators were regularly used for termination of CPB and thereafter, and ventilation was performed with high tidal volumes (10–15 mL/kg) and peak inspiratory pressures up to 50 cm H₂O. Hemodynamics, the incidence of RPE and RHF, duration of ventilation, morbidity, and mortality were recorded. Cardiac index was comparable before surgery (2.11 ± 0.09 vs 2.08 ± 0.09 L · min^-1 · m^-2) and 20 min after CPB (2.26 ± 0.09 vs 2.60 ± 0.20 L · min^-1 · m^-2). RPE occurred in 6.1% (Group I) versus 14.3% (Group II), and RHF was observed in 9.1% (Group I) versus 21.4% (Group II). Mortality was 9.1% (Group I) versus 21.4% (Group II). Thus, the avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation after PTE was associated with a low incidence of RPE, RHF, duration of ventilation, and mortality after PTE.

Implications: The avoidance of positive inotropic catecholamines and vasodilators in combination with nonaggressive mechanical ventilation was associ- ated with a low incidence of reperfusion pulmonary edema and/or right heart failure after pulmonary artery thromboendarterectomy.

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