Chronic thromboembolic pulmonary hypertension: the impact of advances in perioperative techniques in patient outcomes

Scudeller, Paula Gobi; Terra-Filho, Mario; Freitas Filho, Orival; Galas, Filomena Regina Barbosa Gomes; Andrade, Tiago Dutra de; Nicotari, Daniela Odnicki; Gobbo, Laura Michelin; Gaiotto, Fabio Antonio; Hajjar, Ludhmila Abrahão; Jatene, Fabio Biscegli

doi:10.36416/1806-3756/e20200435

Paula Gobi Scudeller

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-9935-9990

Mario Terra-Filho

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-8642-5354

Orival Freitas Filho

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-4671-6077

Filomena Regina Barbosa Gomes Galas

Departamento de Cirurgia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0003-0803-403X

Tiago Dutra de Andrade

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0001-7689-1303

Daniela Odnicki Nicotari

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-4500-676X

Laura Michelin Gobbo

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-7172-372X

Fabio Antonio Gaiotto

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0002-1615-2557

Ludhmila Abrahão Hajjar

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0001-5645-2055

Fabio Biscegli Jatene

Departamento de Cardiopneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

https://orcid.org/0000-0001-6175-5595

Correspondence to: Fabio Biscegli Jatene. Av. Dr. Enéas de Carvalho Aguiar, 44, CEP 05403-900. São Paulo, SP, Brasil. Tel.: +55 11 2661-5695 / Fax: +55 11 2661-5928. E-mail: fabio.jatene@incor.usp.br

AUTHOR CONTRIBUTIONS

PGS: collaborated in the idealization of this work, construction of the database, data collection, data analysis, drafting the article and reviewing it. MT-F: collaborated in the direction of this work, from initial ideation to the final revision of Article. OFF: collaborated in the construction of the new surgery protocol, performing the surgeries, in the construction of the database, analysis and review of the article. TDA: collaborated in database construction, data analysis and revision of Article. DON: collaborated in the standardization of data collection and in the data collection itself. LMG: collaborated in data collection. FAG: collaborated in the construction of the new surgical protocol and in performing the surgeries using the new protocol. LAH: collaborated to write the article and review it. FRBGG: collaborated in the construction of the new surgical protocol and in the anesthesia of the operated cases. FBJ: collaborated in the idealization of this work, construction of the database, data analysis, drafting the article and reviewing it.

Standardization of	1st improvement (January 2013)	2nd improvement (April 2015)
Cardiopulmonary bypass	• Cooling duration at least 70 min (up to 15°C)	• Reduction by half of the total volume of the dilutional prime
	• Rewarm duration at least 90 min (up to 36°C)	• Invasive blood pressure monitoring in the radial artery
		• Temperature control with tympanic thermometer
		• Brain monitoring with BIS
		• Cooling jacket of the head after anesthetic induction
Deep hypothermic circulatory arrest	• Each period to up to 20 min	• None
Deep hypothermic circulatory arrest	• Reperfusion of 10 min between each DHCA	• None
Anesthetic procedure	• None	• Standardization of drugs in anesthetic induction
		• Hemodynamic control of PH with dopamine and phenylephrine
		• Femoral artery catheterization
		• Zero fluid balance (avoiding positive balance)
		• Use of transesophageal echocardiography
		• Use of Cell Saver®
		• Decrease in allogeneic transfusion
Surgical procedure	• None	• Cross-cannulation of the vena cava for the installation of CPB
		• Installation of a cannula for drainage of cardiac cavities
		• Use of thinner polypropylene yarns (6.0 and 7.0) for arteriorrhaphy
		• Use of biological glue after arteriorrhaphy

Outcomes, n (%)	Group 1 (n=38)	Group 2 (n=35)	Group 3 (n=29)	P ^* * P value from the chi-square test (Mantel-Haenszel); p<0.05 was considered significant; n total number of patients.
Pulmonary reperfusion edema	5 (13.2%)	3 (8.6%)	5 (17.2%)	0.674
Acute kidney injury	7 (18.4%)	2 (5.7%)	4 (13.8%)	0.497
Surgical complications	13 (34.2%)	11 (31.4%)	3 (10.3%)	0.035
Bleeding	12 (31.5%)	9 (25.7%)	3 (10.3%)	0.047
Pericardial effusion	3 (7.8%)	6 (17.1%)	2 (6.9%)	0.991
Reoperation	11 (29.0%)	6 (17.1%)	3 (10.3%)	0.055
Infectious complications	12 (31.6%)	8 (22.9%)	5 (17.2%)	0.173
Mediastinitis	4 (10.5%)	2 (5.7%)	1 (3.5%)	0.249
Septic shock	10 (26.3%)	7 (20.0%)	5 (17.2%)	0.363
Neurologic complications	10 (26.3%)	8 (22.8%)	2 (6.9%)	0.055
Delirium	6 (15.7%)	8 (22.8%)	2 (6.9%)	0.384
Stroke	5 (13.2%)	0 (0.0%)	0 (0.0%)	0.010
In-hospital mortality	9 (23.6%)	8 (22.9%)	3 (10.3%)	0.192

Variable	OR (95% CI)	P
Surgical complications
Group
G1	Reference
G2	0.755 (0.250–2.275)	0.574
G3	0.221 (0.052–0.939)	0.034
Estimated PASP (mmHg)	1.031 (1.007–1.056)	0.012
Infectious complications
NYHA class
I/II	Reference
III/IV	3.538 (1.107–11.309)	0.033
In-hospital mortality
Age (years)	1.061 (1.018–1.105)	0.047
PVR (dyn.s.cm^-5)	1.002 (1.001–1.003)	0.024

Variable	Group 1 (n=29)	Group 2 (n=27)	Group 3 (n=26)	P
NYHA class, n (%)				0.385^* * P value from the chi-square test (Mantel-Haenszel);
I	21 (75.0%)	16 (61.5%)	12 (63.1%)
II	6 (21.4%)	9 (34.6%)	6 (31.5%)
III	1 (3.5%)	1 (3.8%)	1 (5.2%)
mPAP, mmHg (mean ± SD)	28 ± 9.7	30.4 ± 8.4	30.6 ± 14.3	0.661⁺ + P value from analysis of variance (ANOVA); n, patients with assessment; p<0.05 was considered significant.
RVP, dynas.s.cm^-5 (mean ± SD)	248.3 ± 99.3	301 ± 257.6	317.7 ± 265.2	0.518⁺
Residual hypertension, n (%)	13 (50%)	16 (72.7%)	9 (50%)	0.852*
Pulmonary vasodilator therapy, n (%)	1 (3.4%)	1 (3.8%)	2 (9.5%)	0.367*

[1] Correspondence to: Fabio Biscegli Jatene. Av. Dr. Enéas de Carvalho Aguiar, 44, CEP 05403-900. São Paulo, SP, Brasil. Tel.: +55 11 2661-5695 / Fax: +55 11 2661-5928. E-mail: fabio.jatene@incor.usp.br

Brasil

Brasil

Chronic thromboembolic pulmonary hypertension: the impact of advances in perioperative techniques in patient outcomes^* * Thesis defended in Programa de Cirurgia Torácica e Cardiovascular, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

ABSTRACT

Objectives

Methods

Results

Conclusion

Brasil

Brasil

Chronic thromboembolic pulmonary hypertension: the impact of advances in perioperative techniques in patient outcomes* * Thesis defended in Programa de Cirurgia Torácica e Cardiovascular, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.

ABSTRACT

Objectives

Methods

Results

Conclusion

Chronic thromboembolic pulmonary hypertension: the impact of advances in perioperative techniques in patient outcomes^* * Thesis defended in Programa de Cirurgia Torácica e Cardiovascular, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP), Brasil.