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Electronic Comments to:
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Electronic comments posted:
![[Read eComment]](/icons/misc/sectionDOWN.gif){kind=icon}
eComment. Surgical options in emergency pulmonary embolectomy
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Salvatore Lentini Cardiac Surgery Unit, Policlinic Hospital, University of Messina. 98100 Messina, Italy, Fabrizio Tancredi, Francesco Monaco, Roberto Gaeta
salvolentini{at}alice.it Salvatore Lentini, et al.
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Interactive CardioVascular and Thoracic Surgery 2008,
doi:10.1510/icvts.2008.176024A © 2008 European Association of Cardio-Thoracic Surgery We read with interest the article of Augoustides and co-workers. We congratulate the authors for the successful result of the treatment, which in these acute patients is not always easy to obtain [1]. The authors describe a case of mechanical obstruction of the cardiopulmonary bypass (CPB) venous cannula during pulmonary embolectomy. They describe a 43-year-old lady with respiratory distress syndrome and consecutive acute severe hypotension. The pre-operative echocardiogram was consistent with massive acute pulmonary embolism, and it had showed already “serpentine thromboemboli in the right atrium”. With the present e-comment we would like to discuss some surgical details. In particular the choice of right atrial cannulation at the start of CPB, and the choice of the aorta cross-clamping. Concerning the choice of right atrium cannulation, the authors explain that this conduct of CPB was deliberately chosen to minimize the risk of thromboembolism, with a manoeuvre performed with a minimal touch technique. We suppose with the aim to decreasing the tension on the right heart, and changing to a bicaval cannulation afterward. In our experience of pulmonary embolectomy in emergency, we usually perform a bicaval cannulation at the beginning, even with very unstable patients. We insert one metallic right angle tip cannula directly in the superior vena cava without touching the heart. The other cannula for the inferior vena cava is already connected to the venous line, but is clamped. In this way it is already possible to start a partial cardiopulmonary bypass, and to decrease the tension on the right heart. Then, we proceed to cannulate the inferior vena cava, through a purse string suture done very near to the inferior vena cava, to reduce the manipulation and minimize the risk of embolism. Once cardiopulmonary bypass is fully established we snare both cavae, and we get access to the right atrium, the ventricle, and the pulmonary arteries. We usually do not cross-clamp the aorta, and we perform the procedure on the beating heart. We manage to obtain a clean surgical field using adequate suction and eventually some very short periods of reduced CPB flow. This, in order to avoid myocardial ischemia. To minimize the risk of embolism another option in cases with thrombus inside the right atrium diagnosed by echocardiography is the venous drainage of the lower part of the body obtained via a femoral cannulation using a long cannula in the inferior vena cava, and cannulation of the superior vena cava through a direct approach or through jugular cannulation as we usually do in minimally invasive heart port technique. References [1] Augoustides J, Plappert T, Bavaria JE. Hemodynamic collapse during pulmonary embolectomy due to loss of venous return from acute occlusion of the cardiopulmonary venous cannula with thromboembolus. Interact CardioVasc Thorac Surg doi:10.1510/icvts.2008.176024 |
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