Minimally Invasive Pulmonary Thromboendarterectomy: A Novel Technique
Michael M. Madani, Jill R. Higgins.
University of California San Diego, La Jolla, CA, USA.
Objective:Pulmonary thromboendarterectomy (PTE) is a complex surgical procedure for the treatment of Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Traditionally the procedure requires median sternotomy, cardiopulmonary bypass with profound hypothermia, and circulatory arrest for a complete endarterectomy. Given the advantages of minimally invasive cardiac surgery, we developed a novel technique to perform the procedure through a minimally invasive approach, avoiding sternotomy. Methods:Laboratory experiments proved feasibility of performing a full endarterectomy, without sternotomy, into distal segmental and subsegmental arteries. The procedure was then offered through mini anterior thoracotomies, without changing any of the established principles, i.e. profound hypothermic circulatory arrest, identification of the correct plane, and a complete bilateral pulmonary endarterectomy. Using a preoperative CT Scan for surgical planning, the procedure is performed utilizing the second or third intercostal space. The arterial cannula is placed centrally in the ascending aorta, and venous cannulae in the femoral vein and right internal jugular vein. In order to maximize working space, and given short periods of circulatory arrests, we avoid using cross-clamp and cardioplegia. Pulmonary artery, left atrial, and aortic root vents are used. The usual protocol for circulatory arrest and exposure of the pulmonary arteries is used. Results:A total of ten minimally invasive PTE surgeries have been performed. Patients were selected based on their anatomical suitability, location of the thromboembolic disease, and the severity of pulmonary hypertension. Morbidly obese patients and patients who required concomitant cardiac procedures were excluded. All ten MIS PTE patients had excellent outcomes without any major events. MIS patients had shorter circulatory arrest times, and shorter length of stay, with significant reduction in PVR. Conclusion:PTE surgery is a complex procedure with a steep learning curve, however with growing experience it is possible to offer this procedure through MIS approach. Based on our small cohort of patients, we have shown that MIS PTE can be performed safely in select group of patients with excellent outcomes. Further experience is required to determine how this novel surgical technique compares to Sternotomy PTE.
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