Traitement chirurgical de la maladie thromboembolique pulmonaire chronique

An improved technique for pulmonary endarterectomy

We report a modified technique for pulmonary endarterectomy (PEA) on a 67-year-old man with chronic thromboembolic pulmonary hypertension (CTEPH) who presented with dyspnea. He was referred to our medical center for coronary artery bypass grafting. CTEPH had not been detected in his first visit to another medical center, but upon re-evaluation, the diagnosis was confirmed. PEA was performed with a modified method, which seems to be safe and suitable for the removal of clot and fibrotic materials. Iatrogenic dissection was performed with normal saline injection in the pulmonary artery, and then, the clot was removed completely. Although the technique may not be applicable for all cases, it can be used as an alternative to using an aspirating dissector and a pair of forceps.

[Invasion of the pulmonary artery by an undifferentiated carcinoma]

INTRODUCTION

The diagnosis of chronic obstruction of the pulmonary artery is difficult. We present the case of a woman with an invasive, undifferentiated carcinoma of the pulmonary artery.

CASE REPORT

A 61 year old woman complained of increasing dyspnoea. This was evaluated by computed tomography which showed a defect in the main pulmonary artery. There was no clinical or radiological improvement following anticoagulant treatment for two months. A repeat CT scan showed a persisting intravascular defect and the diagnoses considered included post-embolic pulmonary arterial hypertension and angiosarcoma. A surgical biopsy was performed and pericardial and aortic tumour nodules were found during the operation. The pathological examination revealed undifferentiated carcinoma. Further investigations failed to reveal the primary site.

CONCLUSION

Invasion of the pulmonary artery by angiosarcoma or other tumour is part of the differential diagnosis of chronic thromboembolic disease. The diagnosis rests on histology obtained by an intravascular or surgical procedure. Complete surgical excision may be possible in angiosarcoma but it was impossible in our patient. The patient died despite two courses of chemotherapy and targeted therapy with erlotinib.

Hypertension pulmonaire postembolique

INTRODUCTION

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare disease characterized by the persistence of thromboemboli obstructing the pulmonary arteries as an organized tissue. The consequence is an increase in pulmonary vascular resistance resulting in pulmonary hypertension (PH) and progressive right heart failure.

BACKGROUND

It is difficult to recognize the postembolic nature of PH because there is no known history of thromboembolic disease in more than 50% of cases. Diagnosis is based on the presence of mismatched segmental defects in the ventilation-perfusion scanning. When CTEPH is suspected, pulmonary angiography and high-resolution CT scan are required to establish the diagnosis and to assess the operability. Pulmonary angiography is always performed in conjunction with a diagnostic right heart catheterization, which is required to confirm the diagnosis of PH and to determine the degree of hemodynamic impairement. If there is a good correlation between the pulmonary vascular resistance and the anatomical obstruction, pulmonary endarterectomy (PEA) must be proposed. Otherwise, vasodilator and antiproliferative treatments and lung transplantation represent interesting alternatives.

VIEWPOINT AND CONCLUSION

PEA remains the treatment of choice for eligible patients. Nevertheless, there is a need to conduct randomized trials to assess the efficacy of novel medical therapies in some situations: (1) in inoperable CTEPH due to distal lesions, (2) before PEA (therapeutic bridge) in patients who are considered "high risk" due to extremely poor hemodynamics, (3) in patients with persistent pulmonary hypertension after surgery.

Surgery for chronic thromboembolic pulmonary hypertension--inclusive experience from a national referral center

BACKGROUND

Chronic thromboembolic pulmonary hypertension represents a unique form of pulmonary hypertension amenable to curative intervention with a pulmonary thromboendarterectomy (PTE). Canada's first successful and sustainable program for PTE surgery was established at the University of Ottawa Heart Institute in 1995. Inclusive results from similarly sized programs are not readily available owing to selective reporting, therefore making it difficult to benchmark outcomes. The purpose of this report is to provide a review of the inclusive results from our moderately sized national program for all PTE, with a particular emphasize on the aspects of the learning curve in terms of patient management.

METHODS

Since 1995, 180 patients have been referred for consideration of PTE, and 106 patients have undergone surgery with a perioperative 30-day mortality rate of 9.4%.

RESULTS

There was a significant improvement in all hemodynamic parameters except right ventricular ejection fraction in nonsurvivors (mean pulmonary artery pressure pre 47 +/- 12 mm Hg versus post 28 +/- 9 mm Hg, p < 0.0001; pulmonary vascular resistance pre 814 +/- 429 dynes x sec(-1) x cm(-5), post 224 +/- 145 dynes x sec(-1) x cm(-5), p < 0.0001; cardiac index pre 2.0 +/- 0.7 L x min(-1) x m(-2), post 3.2 +/- 0.7 L x min(-1) x m(-2), p < 0.0001). A postoperative pulmonary vascular resistance of 500 dynes x sec(-1) x cm(-5) or more was associated with increased perioperative mortality (odds ratio, 12 +/- 8.7; p = 0.001). On average, these procedures were associated with significant resource use involving operating room time (610 +/- 243 minutes), intensive care unit and hospital days (11.2 +/- 13.7 and 19.5 +/- 15.6 days), and ventilation time (7.8 +/- 10.0 days). There was no significant change in hospital or intensive care unit length of stay, or the mortality rate during this first decade.

CONCLUSIONS

PTE programs are resource-intensive surgical specialty services that demand excellence in cardiothoracic expertise. The initial decade reflected an expanding referral basis and likely parallel increases in patient complexity and expertise. The current results at a national referral center have emphasized the importance of centralization of resources to optimize patient outcome.