Table 2-Peroperatif,e Hernotlynamic DtIta* Tl
T2
T3
T4
104 104 60 ~mmHg 9 10 4 6 PC~mmHg 10 10 10 8 MPA~mmHg 50 54 58 29 326 328 139 PaO/FIo. 320 99 97 96 99 SaO. SvO., % 83 77 62 73 CI, Umin/m 2 2.43 1.87 1.52 2.05 SVR, dynes·seems 1,044 2,125 2,728 1,115 PVR, dynes·seems 836 995 1,893 434 O. TR, mllmn/ml 725 526 960 672 O. CONS, mllmnlmJ 188 174 191 184 0 0.16 Epinephrine, ...Wkwmin 0.4 0.1 0 0.015 0.019 PGE I , ...~Wmin 0 MA~mmHg
69
*Tl =after induction of anesthesia; T2 =immediately before right pulmonary artery clamping; T2 = during the graft implantation; T4 =30 min after graft reperfusion. MAP =systemic arterial pressure; CVP =central venous pressure; PCW =pulmonary capillary wedge pressure; MPAP = mean pulmonary arterial pressure; SvO. = mixed venous oxygen saturation; CI = cardiac index; SVR =systemic vascular resistance; PVR =pulmonary vascular resistance; O2 TR = oxygen transport; O2 CONS = oxygen consumption. (0.1 ...w1cg). Hemodynamic measurements were recorded after induction of anesthesia (Tl), immediately before right pulmonary artery clamping (T2), during the graft implantation (T3), and 30 min after graft reperfusion (T4). Increments of Fentanyl and flunitrazepam were administered before clamping. Prostaglandin E. (PGE.) and epinephrine were administered to decrease MPAP and increase mean systemic arterial pressure (MAP), respectively (Table 2). During clamping (75 min), PVR increased by 90 percent accompanied by only an 18 percent decrease in cardiac index (CI). SV02 was constantly higher than 60 percent. PVR decreased by 48 percent from Tl to T4. The patient was extubated 15 h after the end of operation and was moved from the intensive care unit after five days. He was discharged from the hospital six weeks later with MPAP of20 mm Hg and normal blood gas values ('Iable 1). DISCUSSION
Single lung transplantation offers several advantages over heart-lung transplantation (HLT). The surgical procedure is technically easier and the waiting time for SLT is less than that for a HLT. This report confinnst that hemodynamics and pulmonary function in patients with PPH are improved by SLT. The increased pulmonary blood flow is well-tolerated by the lung graft without development of pulmonary edema or pulmonary hypertension as predicted by prior animal studies. 5 The particular problem posed by our patient was that there may have been severe hemorrhage if the operation had to be performed with extracorporeal circulation. The patient presented with coagulation defect secondary to portal hypertension and chronic fibrinolysis with thrombocytopenia and major esophageal varices. In this case, carrying out an SLT seemed to be preferable to a HLT as in the latter, hemorrhagic problems are often severe. Once the operation was indicated, we decided to avoid using extracorporeal circulation during the operation for SLl: In this 188
monitoring with a Swan-Ganz catheter allowing measurement of SvOt , we were able to record the effects of clamping the pulmonary artery. Clamping was accompanied by a general increase in pulmonary arteriolar resistance and the effects were added to the ventilatory results of bronchial clamping. To oppose the deleterious effects due to arterial clamping on the kinetics of the right ventricle, coronary perfusion pressure had to be maintained to oppose the increase in intramural pressure of the right ventricle. This was achieved by increasing systemic arterial pressure using epinephrine and adding PGE I to minimize the increase in pulmonary artery pressure. Despite the difference between mean arterial and mean pulmonary arterial pressure increasing from 19 mm Hg to 46 mm Hg during clamping, the right ventricle never showed signs offailure (CVP = 6 mm Hg). It seemed that the increase in systemic vascular resistance as a result of treatment led to a reduction in the cardiac index. This, however, did not result in too great a reduction in oxygen transport despite the effect ofarterial and bronchial clamping on oxygenation. Moreover, deep anesthesia allowed a decrease in oxygen consumption with a reasonable extraction, maintaining an SvOI of 62 percent during 75 min ofclamping. This SLT for the treatment of PPH with low RVEF is possible without CPB. During pulmonary artery clamping, the decrease in CI and the increase in PVR can be tolerated provided 0 1 consumption is low and right ventricular perfusion pressure is maintained with combination of PGE I and epinephrine. wa~
REFERENCES
1 Reitz VA, Wallwork JL, Hunt SA, Pennock JL, Billingham ME, Oyen PE, et ale Heart-lung transplantation. N EngI J Med 1982; 306:557-64
2 Estenne M, Ketelbant ~ Primo G, Yenault JC. Human heartlung transplantation: physiologic aspects of the denervated lung and posttransplant obliterative bronchiolitis. Am Rev Respir Dis 1987; 135:976-78 3 Grossman RF, Frost A, Zamel N, Patterson GA, Cooper JD, Myron PR, et ale Results ofsingle lung transplantation for bilateral pulmonary fibrosis. N Engl J Med 1990; 322:727-33 4 Levine SM, Gibbons WJ, Bryan CL, Walking AD, Brown ~ Barley SR, et ale Single lung transplantation for primary pulmonary hypertension. Chest 1990; 98:1107-15 5 Eishi K, Takazawa A, Nagatsu M, Hirata K, Yamagishi M, Imamura E, et ale Pulmonary flow resistance relationships in allografts after single transplantation in dogs. J Thorac Cardiovasc Surg 1989; 97:24-9
Prolonged Extracorporeal Support for AR S Using SurfaceHeparinized Equlpment* Dookl WiUms, M. D., F. C. C.l!;t and Walter Dembitsky, M.D., F.C.C.l!* *From Sharp Memorial Hospital, San Diego. tDirector, Extraco~real Lung Support Service. *Director, Arti6cial Organs Program. Reprint requests: Dr. Willms, 7901 Frost Street, San Diego 92123 Prolonged ExtracorporeaI Support for ARDS (WIllms, Dembllllky)
Table 1- Physiologic Parameters During ECCO.R* Pre ECCOtR Pa°t PaCOt Cst, mVcm RsO Pa~ cm HsO PEE~cm R.O VE, mVminlkg Flo. PaO/Flo. PaO/PAOt
39 51
T2
T3
T4
104 104 60 ~mmHg 9 10 4 6 PC~mmHg 10 10 10 8 MPA~mmHg 50 54 58 29 326 328 139 PaO/FIo. 320 99 97 96 99 SaO. SvO., % 83 77 62 73 CI, Umin/m 2 2.43 1.87 1.52 2.05 SVR, dynes·seems 1,044 2,125 2,728 1,115 PVR, dynes·seems 836 995 1,893 434 O. TR, mllmn/ml 725 526 960 672 O. CONS, mllmnlmJ 188 174 191 184 0 0.16 Epinephrine, ...Wkwmin 0.4 0.1 0 0.015 0.019 PGE I , ...~Wmin 0 MA~mmHg
69
*Tl =after induction of anesthesia; T2 =immediately before right pulmonary artery clamping; T2 = during the graft implantation; T4 =30 min after graft reperfusion. MAP =systemic arterial pressure; CVP =central venous pressure; PCW =pulmonary capillary wedge pressure; MPAP = mean pulmonary arterial pressure; SvO. = mixed venous oxygen saturation; CI = cardiac index; SVR =systemic vascular resistance; PVR =pulmonary vascular resistance; O2 TR = oxygen transport; O2 CONS = oxygen consumption. (0.1 ...w1cg). Hemodynamic measurements were recorded after induction of anesthesia (Tl), immediately before right pulmonary artery clamping (T2), during the graft implantation (T3), and 30 min after graft reperfusion (T4). Increments of Fentanyl and flunitrazepam were administered before clamping. Prostaglandin E. (PGE.) and epinephrine were administered to decrease MPAP and increase mean systemic arterial pressure (MAP), respectively (Table 2). During clamping (75 min), PVR increased by 90 percent accompanied by only an 18 percent decrease in cardiac index (CI). SV02 was constantly higher than 60 percent. PVR decreased by 48 percent from Tl to T4. The patient was extubated 15 h after the end of operation and was moved from the intensive care unit after five days. He was discharged from the hospital six weeks later with MPAP of20 mm Hg and normal blood gas values ('Iable 1). DISCUSSION
Single lung transplantation offers several advantages over heart-lung transplantation (HLT). The surgical procedure is technically easier and the waiting time for SLT is less than that for a HLT. This report confinnst that hemodynamics and pulmonary function in patients with PPH are improved by SLT. The increased pulmonary blood flow is well-tolerated by the lung graft without development of pulmonary edema or pulmonary hypertension as predicted by prior animal studies. 5 The particular problem posed by our patient was that there may have been severe hemorrhage if the operation had to be performed with extracorporeal circulation. The patient presented with coagulation defect secondary to portal hypertension and chronic fibrinolysis with thrombocytopenia and major esophageal varices. In this case, carrying out an SLT seemed to be preferable to a HLT as in the latter, hemorrhagic problems are often severe. Once the operation was indicated, we decided to avoid using extracorporeal circulation during the operation for SLl: In this 188
monitoring with a Swan-Ganz catheter allowing measurement of SvOt , we were able to record the effects of clamping the pulmonary artery. Clamping was accompanied by a general increase in pulmonary arteriolar resistance and the effects were added to the ventilatory results of bronchial clamping. To oppose the deleterious effects due to arterial clamping on the kinetics of the right ventricle, coronary perfusion pressure had to be maintained to oppose the increase in intramural pressure of the right ventricle. This was achieved by increasing systemic arterial pressure using epinephrine and adding PGE I to minimize the increase in pulmonary artery pressure. Despite the difference between mean arterial and mean pulmonary arterial pressure increasing from 19 mm Hg to 46 mm Hg during clamping, the right ventricle never showed signs offailure (CVP = 6 mm Hg). It seemed that the increase in systemic vascular resistance as a result of treatment led to a reduction in the cardiac index. This, however, did not result in too great a reduction in oxygen transport despite the effect ofarterial and bronchial clamping on oxygenation. Moreover, deep anesthesia allowed a decrease in oxygen consumption with a reasonable extraction, maintaining an SvOI of 62 percent during 75 min ofclamping. This SLT for the treatment of PPH with low RVEF is possible without CPB. During pulmonary artery clamping, the decrease in CI and the increase in PVR can be tolerated provided 0 1 consumption is low and right ventricular perfusion pressure is maintained with combination of PGE I and epinephrine. wa~
REFERENCES
1 Reitz VA, Wallwork JL, Hunt SA, Pennock JL, Billingham ME, Oyen PE, et ale Heart-lung transplantation. N EngI J Med 1982; 306:557-64
2 Estenne M, Ketelbant ~ Primo G, Yenault JC. Human heartlung transplantation: physiologic aspects of the denervated lung and posttransplant obliterative bronchiolitis. Am Rev Respir Dis 1987; 135:976-78 3 Grossman RF, Frost A, Zamel N, Patterson GA, Cooper JD, Myron PR, et ale Results ofsingle lung transplantation for bilateral pulmonary fibrosis. N Engl J Med 1990; 322:727-33 4 Levine SM, Gibbons WJ, Bryan CL, Walking AD, Brown ~ Barley SR, et ale Single lung transplantation for primary pulmonary hypertension. Chest 1990; 98:1107-15 5 Eishi K, Takazawa A, Nagatsu M, Hirata K, Yamagishi M, Imamura E, et ale Pulmonary flow resistance relationships in allografts after single transplantation in dogs. J Thorac Cardiovasc Surg 1989; 97:24-9
Prolonged Extracorporeal Support for AR S Using SurfaceHeparinized Equlpment* Dookl WiUms, M. D., F. C. C.l!;t and Walter Dembitsky, M.D., F.C.C.l!* *From Sharp Memorial Hospital, San Diego. tDirector, Extraco~real Lung Support Service. *Director, Arti6cial Organs Program. Reprint requests: Dr. Willms, 7901 Frost Street, San Diego 92123 Prolonged ExtracorporeaI Support for ARDS (WIllms, Dembllllky)
Table 1- Physiologic Parameters During ECCO.R* Pre ECCOtR Pa°t PaCOt Cst, mVcm RsO Pa~ cm HsO PEE~cm R.O VE, mVminlkg Flo. PaO/Flo. PaO/PAOt
39 51
