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Kianzad A, Baccelli A, Braams NJ, Andersen S, van Wezenbeek J, Wessels JN, Celant LR, Vos AE, Davies R, Lo Giudice F, Haji G, Rinaldo RF, Vigo B, Gopalan D, Symersky P, Winkelman JA, Boonstra A, Nossent EJ, Tim Marcus J, Vonk Noordegraaf A, Meijboom LJ, de Man FS, Andersen A, Howard LS, Bogaard HJ. Long-term effects of pulmonary endarterectomy on pulmonary hemodynamics, cardiac function, and exercise capacity in chronic thromboembolic pulmonary hypertension. J Heart Lung Transplant 2024; 43:580-593. [PMID: 38000764 DOI: 10.1016/j.healun.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 11/06/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Long-term changes in exercise capacity and cardiopulmonary hemodynamics after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been poorly described. METHODS We analyzed the data from 2 prospective surgical CTEPH cohorts in Hammersmith Hospital, London, and Amsterdam UMC. A structured multimodal follow-up was adopted, consisting of right heart catheterization, cardiac magnetic resonance imaging, and cardiopulmonary exercise testing before and after PEA. Preoperative predictors of residual pulmonary hypertension (PH; mean pulmonary artery pressure >20 mm Hg and pulmonary vascular resistance ≥2 WU) and long-term exercise intolerance (VO2max <80%) at 18 months were analyzed. RESULTS A total of 118 patients (61 from London and 57 from Amsterdam) were included in the analysis. Both cohorts displayed a significant improvement of pulmonary hemodynamics, right ventricular (RV) function, and exercise capacity 6 months after PEA. Between 6 and 18 months after PEA, there were no further improvements in hemodynamics and RV function, but the proportion of patients with impaired exercise capacity was high and slightly increased over time (52%-59% from 6 to 18 months). Long-term exercise intolerance was common and associated with preoperative diffusion capacity for carbon monoxide (DLCO), preoperative mixed venous oxygen saturation, and postoperative PH and right ventricular ejection fraction (RVEF). Clinically significant RV deterioration (RVEF decline >3%; 5 [9%] of 57 patients) and recurrent PH (5 [14%] of 36 patients) rarely occurred beyond 6 months after PEA. Age and preoperative DLCO were predictors of residual PH post-PEA. CONCLUSIONS Restoration in exercise tolerance, cardiopulmonary hemodynamics, and RV function occurs within 6 months. No substantial changes occurred between 6 and 18 months after PEA in the Amsterdam cohort. Nevertheless, long-term exercise intolerance is common and associated with postoperative RV function.
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Affiliation(s)
- Azar Kianzad
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Andrea Baccelli
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Natalia J Braams
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Stine Andersen
- Aarhus University Hospital, Department of Cardiology, Aarhus, Denmark
| | - Jessie van Wezenbeek
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Jeroen N Wessels
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Lucas R Celant
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Anna E Vos
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands
| | - Rachel Davies
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Francesco Lo Giudice
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gulammehdi Haji
- National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rocco F Rinaldo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Beatrice Vigo
- Respiratory Unit, ASST Santi Paolo e Carlo, San Carlo Hospital, Department of Health Sciences, University of Milan, Milan, Italy
| | - Deepa Gopalan
- Department of Radiology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Petr Symersky
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Cardiothoracic Surgery, Amsterdam, the Netherlands
| | - Jacobus A Winkelman
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Cardiothoracic Surgery, Amsterdam, the Netherlands
| | - Anco Boonstra
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Esther J Nossent
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - J Tim Marcus
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - Anton Vonk Noordegraaf
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Lilian J Meijboom
- Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Radiology and Nuclear Medicine, Amsterdam, the Netherlands
| | - Frances S de Man
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands
| | - Asger Andersen
- Aarhus University Hospital, Department of Cardiology, Aarhus, Denmark
| | - Luke S Howard
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; National Pulmonary Hypertension Service, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Harm Jan Bogaard
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department of Pulmonary Medicine, Amsterdam, the Netherlands; Amsterdam Cardiovascular Sciences, Pulmonary Hypertension and Thrombosis, Amsterdam, the Netherlands.
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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Durrington C, Hurdman JA, Elliot CA, Maclean R, Van Veen J, Saccullo G, De-Foneska D, Swift AJ, Smitha R, Hill C, Thomas S, Dwivedi K, Alabed S, Wild JM, Charalampopoulos A, Hameed A, Rothman AMK, Watson L, Hamilton N, Thompson AAR, Condliffe R, Kiely DG. Systematic pulmonary embolism follow-up increases diagnostic rates of chronic thromboembolic pulmonary hypertension and identifies less severe disease: results from the ASPIRE Registry. Eur Respir J 2024; 63:2300846. [PMID: 38302154 PMCID: PMC7615743 DOI: 10.1183/13993003.00846-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/21/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND Diagnostic rates and risk factors for the subsequent development of chronic thromboembolic pulmonary hypertension (CTEPH) following pulmonary embolism (PE) are not well defined. METHODS Over a 10-year period (2010-2020), consecutive patients attending a PE follow-up clinic in Sheffield, UK (population 554 600) and all patients diagnosed with CTEPH at a pulmonary hypertension (PH) referral centre in Sheffield (referral population estimated 15-20 million) were included. RESULTS Of 1956 patients attending the Sheffield PE clinic 3 months following a diagnosis of acute PE, 41 were diagnosed with CTEPH with a cumulative incidence of 2.10%, with 1.89% diagnosed within 2 years. Of 809 patients presenting with pulmonary hypertension (PH) and diagnosed with CTEPH, 32 were Sheffield residents and 777 were non-Sheffield residents. Patients diagnosed with CTEPH at the PE follow-up clinic had shorter symptom duration (p<0.01), better exercise capacity (p<0.05) and less severe pulmonary haemodynamics (p<0.01) compared with patients referred with suspected PH. Patients with no major transient risk factors present at the time of acute PE had a significantly higher risk of CTEPH compared with patients with major transient risk factors (OR 3.6, 95% CI 1.11-11.91; p=0.03). The presence of three computed tomography (CT) features of PH in combination with two or more out of four features of chronic thromboembolic pulmonary disease at the index PE was found in 19% of patients who developed CTEPH and in 0% of patients who did not. Diagnostic rates and pulmonary endarterectomy (PEA) rates were higher at 13.2 and 3.6 per million per year, respectively, for Sheffield residents compared with 3.9-5.2 and 1.7-2.3 per million per year, respectively, for non-Sheffield residents. CONCLUSIONS In the real-world setting a dedicated PE follow-up pathway identifies patients with less severe CTEPH and increases population-based CTEPH diagnostic and PEA rates. At the time of acute PE diagnosis the absence of major transient risk factors, CT features of PH and chronic thromboembolism are risk factors for a subsequent diagnosis of CTEPH.
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Affiliation(s)
- Charlotte Durrington
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Judith A Hurdman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Charlie A Elliot
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Rhona Maclean
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joost Van Veen
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Giorgia Saccullo
- Department of Haematology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Duneesha De-Foneska
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew J Swift
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Rajaram Smitha
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Catherine Hill
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Steven Thomas
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Krit Dwivedi
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Samer Alabed
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - James M Wild
- Department of Radiology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Athanasios Charalampopoulos
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - Alexander M K Rothman
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Neil Hamilton
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
| | - A A Roger Thompson
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
| | - David G Kiely
- Sheffield Pulmonary Vascular Disease Unit, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- Insigneo Institute, University of Sheffield, Sheffield, UK
- National Institute for Health and Care Research Sheffield Biomedical Research Centre, Sheffield, UK
- R. Condliffe and D.G. Kiely contributed equally to this work
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Yang J, Madani MM, Mahmud E, Kim NH. Evaluation and Management of Chronic Thromboembolic Pulmonary Hypertension. Chest 2023; 164:490-502. [PMID: 36990148 PMCID: PMC10410247 DOI: 10.1016/j.chest.2023.03.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 03/11/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a treatable form of pulmonary hypertension and right heart failure. CTEPH (group 4 pulmonary hypertension) is caused by persistent organized thromboembolic obstruction of the pulmonary arteries from incompletely resolved acute pulmonary embolism. CTEPH also may present without prior VTE history, which can contribute to its underrecognition. The true incidence of CTEPH is unclear, but is estimated to be approximately 3% after acute pulmonary embolism. V˙/Q˙ scintigraphy is the best screening test for CTEPH, with CT scan imaging and other advanced imaging methods now playing a larger role in disease detection and confirmation. Perfusion defects on V˙/Q˙ scintigraphy in the setting of pulmonary hypertension are suggestive of CTEPH, but pulmonary angiography and right heart catheterization are required for confirmation and treatment planning. CTEPH potentially is curative with pulmonary thromboendarterectomy surgery, with mortality rates of approximately 2% at expert centers. Advances in operative techniques are allowing more distal endarterectomies to be performed successfully with favorable outcomes. However, more than one-third of patients may be considered inoperable. Although these patients previously had minimal therapeutic options, effective treatments now are available with pharmacotherapy and balloon pulmonary angioplasty. Diagnosis of CTEPH should be considered in all patients with suspicion of pulmonary hypertension. Treatments for CTEPH have advanced with improvements in outcomes for both operable and inoperable patients. Therapy should be tailored based on multidisciplinary team evaluation to ensure optimal treatment response.
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Affiliation(s)
- Jenny Yang
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA
| | - Michael M Madani
- Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, CA
| | - Ehtisham Mahmud
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA
| | - Nick H Kim
- Division of Pulmonary, Critical Care, Sleep Medicine, University of California, San Diego, La Jolla, CA.
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Samanidis G, Kanakis M, Perreas K. Can regional cerebral oxygen saturation monitoring during circulatory arrest time predict postoperative neurological dysfunction in patients undergoing surgical pulmonary thromboendarterectomy? Useful index for short- and long-term outcomes. J Card Surg 2022; 37:2386-2388. [PMID: 35578157 DOI: 10.1111/jocs.16612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/29/2022]
Abstract
A hypothermic circulatory arrest is usually used to correct thoracic aorta pathologies. The emergency treatment of acute type A aortic dissection and elective repair of aortic arch pathologies are the most common indications for using hypothermic circulatory arrest. A hypothermic circulatory arrest can also be used for surgical pulmonary thromboendarterectomy in patients with chronic thromboembolic pulmonary hypertension. Intervals with total circulatory arrest offer a clear surgical field for thrombus and emboli removal from the pulmonary artery branches. The price to pay for intermittent circulatory arrest during pulmonary thromboendarterectomy is postoperative neurological dysfunction due to brain hypothermia and hypoperfusion. A noninvasive method for cerebral monitoring during cardiac surgery is real-time regional cerebral oxygen saturation (rSO2 ). Liu et al. report that continuous monitoring of rSO2 during surgical pulmonary thromboendarterectomy may reduce the long cerebral hypoperfusion time and prevent postoperative neurological dysfunction.
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Affiliation(s)
- George Samanidis
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Konstantinos Perreas
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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