Circulatory arrest versus cerebral perfusion during pulmonary endarterectomy surgery (PEACOG): a randomised controlled trial.

BACKGROUND: For some surgical procedures to be done, a patient's blood circulation needs to be stopped. In such situations, the maintenance of blood flow to the brain is perceived beneficial even in the presence of deep hypothermia. We aimed to assess the benefits of the maintenance of antegrade cerebral perfusion (ACP) compared with deep hypothermic circulatory arrest (DHCA). METHODS: Patients aged 18-80 years undergoing pulmonary endarterectomy surgery in a UK centre (Papworth Hospital, Cambridge) were randomly assigned with a computer generated sequence to receive either DHCA for periods of up to 20 min at 20°C or ACP (1:1 ratio). The primary endpoint was change in cognitive function at 12 weeks after surgery, as assessed by the trail-making A and B tests, the Rey auditory verbal learning test, and the grooved pegboard test. Patients and assessors were masked to treatment allocation. Primary analysis was by intention to treat. The trial is registered with Current Controlled Trials, number ISRCTN84972261. FINDINGS: We enrolled 74 of 196 screened patients (35 to receive DHCA and 39 to receive ACP). Nine patients crossed over from ACP to DHCA to allow complete endarterectomy. At 12 weeks, the mean difference between the two groups in Z scores (the change in cognitive function score from baseline divided by the baseline SD) for the three main cognitive tests was 0·14 (95% CI -0·14 to 0·42; p=0·33) for the trail-making A and B tests, -0·06 (-0·38 to 0·25; p=0·69) for the Rey auditory verbal learning test, and 0·01 (-0·26 to 0·29; p=0·92) for the grooved pegboard test. All patients showed improvement in cognitive function at 12 weeks. We recorded no significant difference in adverse events between the two groups. At 12 weeks, two patients had died (one in each group) [corrected]. INTERPRETATION: Cognitive function is not impaired by either ACP or DHCA. We recommend circulatory arrest as the optimum modality for patients undergoing pulmonary endarterectomy surgery. FUNDING: J P Moulton Charitable Foundation.

Intractable ventricular tachycardia secondary to cardiac hemangioma.

Cardiac tumors are rare and have a known association with ventricular dysrhythmias, especially ventricular tachycardia. We report a case of intractable ventricular tachycardia in a middle-aged man developing on a background of known, presumed benign, cardiac neoplasm. The ventricular tachycardia was controlled with long-term medical therapy. Surgical resection of the cardiac mass combined with cryoablation cured the dysrhythmia. Appearances at histopathology were those of a benign intracardiac hemangioma. Surgical treatment has an important but forgotten role in the management of ventricular arrhythmias, which is more definitive and carries a higher success rate compared with medical management.

Successful extracorporeal membrane oxygenation support after pulmonary thromboendarterectomy.

BACKGROUND: Pulmonary thromboendarterectomy (PTE) is the treatment of choice for patients with chronic thromboembolic pulmonary hypertension. However, some patients develop severe cardiorespiratory compromise soon after separating from cardiopulmonary bypass, either from early reperfusion pulmonary edema or right ventricular failure secondary to residual pulmonary hypertension. Since 2005 we have used venoarterial extracorporeal membrane oxygenation (ECMO) support in this group that has no other therapeutic option. We review our experience of early ECMO support in the severely compromised patient's post-PTE. METHODS: We conducted a retrospective review of all patients undergoing PTE from a single national referral center between August 2005 and August 2007. RESULTS: One hundred twenty-seven consecutive patients underwent PTE surgery. Seven patients (5.5%) had extreme cardiorespiratory compromise in the immediate postoperative period and required venoarterial ECMO support. Their mean age was 51.3 years with 3 males. When compared with patients not requiring ECMO, these patients had significantly poorer hemodynamic indices before the operation with mean pulmonary artery pressure of 62 mm Hg versus 51 mm Hg (p = 0.02) and pulmonary vascular resistance of 907 dynes/sec/cm(-5) versus 724 dynes/s(-1)/cm(-5) (p < 0.02). Mean duration of support was 119 hours (49 to 359 hours). Five patients were successfully weaned from ECMO support (73%) and 4 left the hospital alive, giving a salvage rate of 57%. For those who did not require ECMO support, hospital mortality was 4.2%. CONCLUSIONS: Early venoarterial ECMO support has a role as rescue therapy post-PTE in patients with severe compromise who would probably otherwise die.