Gerard R. Manecke

Pulmonary endarterectomy: experience and lessons learned in 1,500 cases

BACKGROUND The incidence of pulmonary hypertension resulting from chronic thrombotic occlusion of the pulmonary arteries is significantly underestimated. Although medical therapy for the condition is supportive only, surgical therapy is curative. Our pulmonary endarterectomy program was begun in 1970, and 188 patients were operated on in the subsequent 20 years. With the increased recognition of the disease and the success of operative therapy, however, more than 1,400 operations have been done since 1990 at our center. METHODS The safety and efficacy of the operation was assessed with changes made through increased experience. We examined in detail the results of our last 500 consecutive patients. RESULTS Median sternotomy, cardiopulmonary bypass, profound hypothermia, and circulatory arrest were found to be essential to the success of the operation. All occluding material could be removed at operation. We currently believe that there is no degree of embolic occlusion within the pulmonary vascular tree that is inaccessible and no degree of right ventricular impairment or any level of pulmonary vascular resistance that is inoperable. With shorter cardiac arrest periods and the use of a cooling jacket to the head, cerebral impairment has been eliminated. The pulmonary artery pressures and pulmonary vascular resistance in a recent cohort of 500 patients is examined. The mortality rate for the operation has been reduced steadily, and was 22 of the last 500 patients operated on (4.4%). CONCLUSIONS The operation is considered curative and therefore greatly superior to transplantation for this condition. Current techniques of operation make the procedure relatively safe.

Edwards FloTrac™ sensor and Vigileo™ monitor: easy, accurate, reliable cardiac output assessment using the arterial pulse wave

Edwards Lifesciences has recently introduced the FloTrac™ sensor and Vigileo™ monitor system for monitoring cardiac output continuously. It does not require thermodilution or dye dilution, but rather bases its calculations on arterial waveform characteristics in conjunction with patient demographic data. It is unique among arterial waveform cardiac output systems in that it does not require calibration with another method. Studies thus far indicate that it is robust and accurate over a wide range of cardiac output and clinical conditions. It will be valuable in the care of many patients, such as those with critical illness, cardiovascular dysfunction, trauma or undergoing major surgery.

Massive Pulmonary Hemorrhage After Pulmonary Thromboendarterectomy

Pulmonary thromboendarterectomy, the most common surgical treatment of chronic thromboembolic pulmonary hypertension, is being performed with increasing frequency throughout the world. Massive pulmonary hemorrhage is a potentially fatal complication of this procedure. In this report of three such cases, the diagnosis, clinical course, and possible treatments are discussed. Anesthesiologists involved in the care of patients receiving pulmonary thromboendarterectomy must be aware of the possibility of this complication, as well as the various techniques available for its treatment.

Efficacy of Methylprednisolone in Preventing Lung Injury Following Pulmonary Thromboendarterectomy

BACKGROUND We sought to determine the efficacy and safety of perioperative treatment with methylprednisolone on the development of lung injury after pulmonary thromboendarterectomy. METHODS This was a randomized, prospective, double-blind, placebo-controlled study of 98 adult patients with chronic thromboembolic pulmonary hypertension who were undergoing pulmonary thromboendarterectomy at a single institution. The patients received either placebo (n = 47) or methylprednisolone (n = 51) (30 mg/kg in the cardiopulmonary bypass prime, 500 mg IV bolus following the final circulatory arrest, and 250 mg IV bolus 36 h after surgery). The primary end point was the presence of lung injury as determined by two independent, blinded physicians using prospectively defined criteria. The secondary end points included ventilator-free, ICU-free, and hospital-free days and selected levels of cytokines in the blood and in BAL fluid. RESULTS The incidence of lung injury was similar in both treatment groups (45% placebo, 41% steroid; P = .72). There were no statistical differences in the secondary clinical end points between treatment groups. Treatment with methylprednisolone, compared with placebo, was associated with a statistically significant reduction in plasma IL-6 and IL-8, a significant increase in plasma IL-10, and a significant reduction in postoperative IL-1ra and IL-6, but not IL-8 in BAL fluid obtained 1 day after surgery. CONCLUSIONS Perioperative methylprednisolone does not reduce the incidence of lung injury following pulmonary thromboendarterectomy surgery despite having an antiinflammatory effect on plasma and lavage cytokine levels.

Cardiac Output Determination From Endotracheally Measured Impedance Cardiography: Clinical Evaluation of Endotracheal Cardiac Output Monitor

OBJECTIVES To evaluate the accuracy, precision, and trending of a new endotracheally sourced impedance cardiography-based cardiac output (CO) monitor (ECOM; ConMed Corp, Irvine, CA). SETTING Two university hospitals. PARTICIPANTS Thirty patients scheduled for elective coronary artery bypass graft (CABG) surgery. INTERVENTIONS All patients received a pulmonary artery catheter (PAC), arterial catheter, endotracheal CO monitor (ECOM), endotracheal intubation, and transesophageal echocardiographic monitoring. ECOM CO was compared with CO measured with pulmonary artery thermodilution, and left ventricular CO measured with transesophageal echocardiography. MEASUREMENTS One hundred forty-five pairs of triplicate CO measurements using intermittent bolus pulmonary artery thermodilution (TD) and ECOM were compared at 5 distinct time points: postinduction, postinduction passive leg raise, poststernotomy, post-CABG completion, and post-chest closure. Eighty-seven pairs of triplicate CO measurements using transesophageal echocardiography were obtained at 3 time points: postinduction, post-CABG completion, and post-chest closure and compared with ECOM- and PA-derived CO measurements. The measurements at each time point were compared by using Bland-Altman and polar plot analyses. RESULTS The mean CO ranged from 2.16 to 9.41 L/min. ECOM CO, compared with TD CO, revealed a bias of 0.02 L/min, 95% limits of agreement of -2.26 to 2.30 L/min, and a percent error of 50%. ECOM CO showed trending with TD CO with 91% and 99% of values within 0.5L/min and 1 L/min limits of agreement, respectively. ECOM CO, compared with TEE CO, revealed a bias of -0.25 L/min, 95% limits of agreement of -2.41 to 1.92 L/min, and a percent error of 48%. ECOM CO showed trending with TEE CO with 83% and 95% of values within 0.5L/min and 1 L/min limits of agreement, respectively. CONCLUSION ECOM CO shows an acceptable bias with wide limits of agreement and a large percent error when compared with TD CO or TEE CO; however, it shows acceptable trending of CO to both modalities in patients undergoing cardiac surgery. Further studies are required to evaluate ECOM in other patient populations and clinical situations.

Chronic Thromboembolic Pulmonary Hypertension and Pulmonary Thromboendarterectomy

Chronic thromboembolic pulmonary hypertension results from incomplete resolution of a pulmonary embolus or from recurrent pulmonary emboli. Its incidence is underappreciated, and it is currently an undertreated phenomenon. Pulmonary thromboendarterectomy is currently the safest and most effective treatment for this condition. The surgery involves midline sternotomy, profound hypothermic circulatory arrest, and complete endarterectomy of the pulmonary vascular tree. Success depends on effective coordination of multiple medical teams, including pulmonary medicine, anesthesiology, and surgery. This review, based on the past 30 years of experience at University of California San Diego Medical Center, includes information about the clinical history, diagnostic workup, anesthesia, surgical approach, and postoperative care. Outcome data are discussed, as are avenues for future research.

Tackling the economic burden of postsurgical complications: would perioperative goal-directed fluid therapy help?

IntroductionPay-for-performance programs and economic constraints call for solutions to improve the quality of health care without increasing costs. Many studies have shown decreased morbidity in major surgery when perioperative goal directed fluid therapy (GDFT) is used. We assessed the clinical and economic burden of postsurgical complications in the University HealthSystem Consortium (UHC) in order to predict potential savings with GDFT.MethodsData from adults who had a major surgical procedure in 2011 were screened in the UHC database. Thirteen post-surgical complications were tabulated. In-hospital mortality, hospital length of stay and costs from patients with and without complications were compared. The risk ratios reported by the most recent meta-analysis were used to estimate the potential reduction in post-surgical morbidity with GDFT. Potential cost-savings were calculated from the actual and anticipated morbidity rates.ResultsA total of 75,140 patients met the search criteria, and 8,421 patients developed one or more post-surgical complications (morbidity rate 11.2%). In patients with and without complications, in-hospital mortality was 12.4% and 1.4% (P <0.001), mean hospital length of stay was 20.5 ± 20.1 days and 8.1 ± 7.1 days (P <0.001) and mean direct costs were

An unusual case of pulmonary artery catheter malfunction.

47,284 ± 49,170 and

Pulmonary Endarterectomy Part II. Operation, Anesthetic Management, and Postoperative Care

17,408 ± 15,612 (P <0.001), respectively. With GDFT, morbidity rate was projected to decrease to 8.0 - 9.3%, yielding gross costs savings of

Pulmonary Endarterectomy Part I. Pathophysiology, Clinical Manifestations, and Diagnostic Evaluation of Chronic Thromboembolic Pulmonary Hypertension

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