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Journal of Medicine and Medical Sciences Vol. 3(3) pp. 128-129, March 2012 Available online@ http://www.interesjournals.org/JMMS Copyright 2012 International Research Journals Case Report Antegrade Brain Perfusion for Pulmonary
Thromboendarterectomy
Jean-Francois Morina, François Béiqueb, Andrew Hirschc Patrick Chamound
aCardiac Surgery, SMBD Jewish General Hospital, McGill University b/dDepartment of Anesthesia, SMBD Jewish General Hospital, McGill University cRespiratory Medicine, SMBD Jewish General Hospital, McGill University The gold standard procedure for pulmonary thrombo-endarterectomy is median sternotomy,
cardiopulmonary bypass, profound hypothermia (18°C) and circulatory arrest. In this case, we
modified the technique by cannulation of the right axillary artery and antegrade brain perfusion while
maintaining moderate hypothermia. The aim of this new procedure was to decrease the duration of
surgery and improve the patient’s recovery.

Keywords: Pulmonary thrombo-endarterectomy, brain, circulatory arrest.

CASE REPORT
Mr. JMP is a 59 years old man. His past medical history catheterization revealed a PA pressure of 70/19 mmHg includes asthma, deep vein thrombosis in the right leg 15 with a pulmonary capillary wedge pressure of 10 mmHg. years ago and a pulmonary embolism in 2006. His His right atrial pressure was elevated at 15 mmHg. The medications include Atrovent, Ventolin and Coumadin. cardiac index was 1.7 liters /min/m², coronary The patient had been complaining of increasing angiography was normal and an IVC filter was inserted. shortness of breath (NYHA class IV) for the last few On April 30th, 2008 the patient underwent right and left pulmonary thrombo-endarterectomy. Instead of cooling ECG and chest X-ray were within normal limits. The down the body core temperature to 18ºC, we stopped at echocardiogram estimated the systolic pulmonary artery 25ºC. While having circulatory arrest of 43 minutes for the pressure at 79 mmHg with marked right ventricular right side and 32 min on the left side, we used antegrade dilatation and systolic dysfunction. Moderate tricuspid perfusion of the brain through the right axillary artery. We regurgitation was also observed. The LVEF was completed the surgery with an aortic cross-clamp time of estimated at 45% with mild diastolic dysfunction. A lung 94 minutes and a pump time of 202 minutes. Off V/Q scan showed multiple wedge shaped defects cardiopulmonary bypass, his PA pressures and cardiac especially to the right upper lobe with decreased index were respectively 40/20 and 2.8 L/min/m² on perfusion to the lateral basal segment of the lower lobes milrinone and low dose norepinephrine. Following and multiple segmental defects throughout the left lung. A separation from cardiopulmonary bypass the patient CT-angiogram showed multiple segmental and lobar developed pulmonary hemorrhage (100 cc) through the endotracheal tube during the next hour. This was treated with a peep level of 15 mmHg and inverse I:E ratio unremarkable except for a slightly low DLCO which was (1.5/1.0) in an attempt to tamponade the pulmonary 77% of predicted. The hemodynamics at right heart hemorrhage. Upon arrival to the ICU the hemorrhage had resolved and the patient was extubated the following morning with no further sequalae. The patient developed a superficial sternal wound infection and spent 3 days in the intensive care unit. He was discharged home on day *Corresponding Author E-mail: [email protected]; Tel: (514) 340-8222 ext 5598; Fax: (514) 340-7561 advantage of this new technique is to reduce the operative time. By cooling at 25ºC instead of 18 or 20ºC, The gold standard procedure for pulmonary thrombo- we reduced the re-warming period. For this first case of a endarterectomy is median sternotomy, cardiopulmonary modified procedure, we have been cautious. We limited bypass, profound hypothermia (18 to 20ºC) and the decrease in body temperature to 25ºC but perhaps circulatory arrest. Circulatory arrest is fundamental to this temperature could have been kept at 28 or 32ºC. provide a bloodless field to remove the thrombi in the Further series are necessary to confirm the safety and affected areas of the pulmonary vasculature for the good results of this modified technique. visibility necessary to clear all affected areas of the pulmonary vasculature (Jamieson et al., 2003). In this case, we modified the technique to improve the REFRENCES

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