title: Evolving surgical techniques for pulmonary endarterectomy according to the changing features of chronic thromboembolic pulmonary hypertension patients during 17-year single-center experience.
abstract: OBJECTIVE
  An increasing number of elderly patients are referred for pulmonary endarterectomy. The distinction between operable and inoperable lesions has been challenged over time. Hence, we developed alternative cardiopulmonary bypass management and cerebral protection strategies to obtain satisfactory surgical results according to the changing patient features.
  
  
  METHODS
  From April 1994 to March 2011, 347 pulmonary endarterectomies were performed at our center. We began with the technique championed by the San Diego Group, adopting a single period of deep hypothermic circulatory arrest for each side (group A). Since 2003, we began to perform short periods of intermittent deep hypothermic circulatory arrest followed by periods of reperfusion (group B). We then adopted moderate, instead of deep, hypothermia (group C). Finally, we modified our technique further performing shorter (5-7-minute) periods of circulatory arrest (group D).
  
  
  RESULTS
  The hemodynamic results after surgery were excellent in all 4 groups. The patients' age increased significantly. A trend toward an increase in the number of Jamieson type 3 lesions was observed. Associated with our protocol changes, we observed better postoperative respiratory function, a reduction in the length of mechanical ventilation and postoperative infections, and a remarkable improvement in uneventful postoperative courses. Despite the increased total circulatory arrest time, a trend toward a reduction in the incidence of transient neurologic events was observed, and operative mortality was not affected.
  
  
  CONCLUSIONS
  In our experience, our alternative strategy resulted in a better combination of surgical accuracy and cerebral protection and improved outcomes.
authors.affiliation: Division of Cardiac Surgery, University of Pavia School of Medicine, Foundation IRCCS San Matteo Hospital, Pavia, Italy. m.morsolini@smatteo.pv.it
authors.forename: Marco
authors.initials: M
authors.lastname: Morsolini
authors.forename: Salvatore
authors.initials: S
authors.lastname: Nicolardi
authors.forename: Elisa
authors.initials: E
authors.lastname: Milanesi
authors.forename: Eleonora
authors.initials: E
authors.lastname: Sarchi
authors.forename: Gabriella
authors.initials: G
authors.lastname: Mattiucci
authors.forename: Catherine
authors.initials: C
authors.lastname: Klersy
authors.forename: Andrea Maria
authors.initials: AM
authors.lastname: D'Armini
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods; D016022:Case-Control Studies; D002908:Chronic Disease; D004691:Endarterectomy / Q000639:trends*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D006976:Hypertension, Pulmonary / Q000601:surgery*; D007036:Hypothermia, Induced; D016014:Linear Models; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013997:Time Factors; D016896:Treatment Outcome