Anesthetic management of chronic thromboembolic pulmonary hypertension for surgical pulmonary thromboendarterectomy: A narrative review

Chronic thromboembolic pulmonary hypertension (CTEPH) is caused due to the total or partial occlusion of the pulmonary vasculature due to organized thrombus, leading to severe pulmonary hypertension and eventually right heart failure, which makes anesthetic management very challenging. Pulmonary endarterectomy (PTE) is the treatment of choice for patients with operable CTEPH. The objective of the present review is to examine the preoperative evaluation, anesthesia technique, and postoperative management in the intensive care unit (ICU) of patients with CTEPH after PTE. We identified published journal articles in the last 25 years from PubMed and Google Scholar databases with the keywords "chronic thromboembolic pulmonary hypertension,"" anesthetic management of pulmonary thrombo-endarterectomy," and "perioperative management of CTEPH." One hundred fifty-three articles were reviewed, out of which 30 articles were retrieved finally. Based on the articles reviewed, we inferred that a balanced anesthesia technique should be carefully chosen to avoid hemodynamic collapse. Transesophageal echocardiography (TEE) is used to assess biventricular function, peak pulmonary artery pressure, the severity of tricuspid regurgitation, location and extent of thrombus, and guide pulmonary artery catheter insertion. Deep hypothermic circulatory arrest (DHCA) is utilized to perform a complete endarterectomy into segmental and subsegmental arterial branches. This narrative review article highlights the role of anesthesiologists in preoperative evaluation, intraoperative TEE guidance, anesthetic management, and postoperative management of complications such as reperfusion pulmonary edema, residual pulmonary hypertension, intrapulmonary hemorrhage, and the consequences of DHCA in patients with CTEPH undergoing surgical PTE. Future research is required to study the effects of DHCA and free radical injuryon postoperative complications and its prevention.