Severe re‐expansion pulmonary edema after conventional cardiac surgery: Identification and management

Abstract

Re-expansion Pulmonary Edema (REPE) is a recognized but rare complication of lung re-inflation after pathologic collapse or intentional deflation. The presentation of REPE may be highly variable, ranging from a clinically asymptomatic, incidental radiologic finding to acute respiratory failure accompanied by severe, life-threatening hypoxemia. With the current report, we present a patient with severe aortic insufficiency, severe mitral regurgitation, coronary artery disease, pulmonary hypertension, who underwent aortic valve replacement, mitral valvuloplasty, coronary artery bypass grafting, and developed at the immediate post-operative period severe respiratory failure due to REPE, requiring venous-venous Extracorporeal Membrane Oxygenation (VV-ECMO).

Management of fulminating non-cardiogenic pulmonary edema following cardiac surgery

“…It is often difficult to clarify the etiology of this challenging condition because NCPE is multifactorial. To our knowledge, cases of fulminating NCPE following cardiac surgery which require ECMO are associated with transfusion-related lung injury (TRALI) [ 7 , 8 ], re-expansion pulmonary edema [ 2 , 5 , 6 ] and protamine-induced pulmonary edema [ 9 , 10 ]. In Case 1, the main etiology of alveolar flooding was speculated to be TRALI, although re-expansion of the lungs and protamine administration were also possible causes because all these events occurred during the limited time frame soon after CPB termination.…”

Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report

“…Acute pulmonary edema after cardiac surgery develops due to cardiogenic and non-cardiogenic causes and occasionally leads to severe hypoxemia that cannot be managed with mechanical ventilation alone [ 1 , 2 ]. Unilateral pulmonary edema (UPE) after on-pump minimally invasive cardiac surgeries (MICS) has been increasingly reported [ 3 ].…”

Selective pulmonary artery perfusion revisited

“…We believe that there may be several speculative pathophysiologic concerns that need to be examined. First, it may be argued that discontinuing pulmonary ventilation during cardiopulmonary bypass may be counterproductive for many reasons, such as atelectrauma and re‐expansion pulmonary injury 9 . However, as far as alveolar ischemia mitigation is concerned, the attendant hypoxic pulmonary vasoconstriction could be diverting blood away from the collapsed alveoli, negating the expected benefits of pulmonary artery perfusion.…”

“…First, it may be argued that discontinuing pulmonary ventilation during cardiopulmonary bypass may be counterproductive for many reasons, such as atelectrauma and re-expansion pulmonary injury. 9 However, as far as alveolar ischemia mitigation is concerned, the attendant hypoxic pulmonary vasoconstriction could be diverting blood away from the collapsed alveoli, negating the expected benefits of pulmonary artery perfusion. Second, perfusing the pulmonary artery with oxygenated blood may actually facilitate intra-alveolar inflammatory changes, as the bypass oxygenator is increasingly recognized as a major contributor to activation of systemic inflammatory response during extracorporeal perfusion.…”