Cardiological Aspects of the Perioperative Management of Patients With Chronic Thromboembolic Pulmonary Hypertension for Pulmonary Thromboendarterectomy

Abstract

Aim. To analyze the factors associated with a poor outcome of pulmonary thromboendarterectomy (PTE) and complications of the hospital postoperative period; on the basis of this analysis to optimize preoperative preparation and therapeutic support of the operation. Materials and methods. The study included 47 patients with operable CTEPH, who underwent PTE in the Department of cardiovascular surgery of the national medical research center of cardiology from 2010 to 2018. Patients were observed during the intrahospital period, all were evaluated for clinical, instrumental, hemodynamic, and laboratory parameters. Diagnosis and treatment of complications, assessment of the relationship of factors associated with the development of these pathological conditions were carried out. Results. A comprehensive assessment of the parameters revealed that age over 50 years, the presence of proven antiphospholipid syndrome (AFS) were independently associated with a higher frequency of adverse surgical outcomes and in-hospital complications. Older age and a history of smoking were independently associated with a greater likelihood of developing reperfusion pulmonary edema. The probability of developing transient neurological complications is independently associated with a long duration of deep hypothermic circulatory arrest (DHCA), an increased level of D-dimer. A greater age and longer duration of ventilation are independently associated with the likelihood of developing acute kidney injury (AKI). A higher level of antithrombin III and the presence of AFS were independently associated with the likelihood of developing prolonged ventilation. Conclusion. When selecting candidates for surgery, in addition to the generally accepted clinical and instrumental parameters, it is necessary to take into account a history of Smoking, an increase in d-dimer, and the presence of AFS. Patients with this pathology need a more thorough risk assessment, correction of target levels of activated partial thromboplastin time (aPTT), activated clotting time (ACT) due to their falsely inflated indicators, and further development of standards for perioperative support. The main principle of cardiological support of the operation is the earliest possible diagnosis of all known perioperative complications and the rapid start of their treatment, which ensures the stabilization of the patient’s condition in 85% of cases in the hospital period. In the postoperative period, an early transition from ventilator to independent breathing is indicated for the prevention of associated complications, including AKI.