Management of Post-Operative Patients After Pulmonary Endarterectomy
Post-operative patients following pulmonary endarterectomy require intensive care unit admission with close hemodynamic monitoring, respiratory support, and a multidisciplinary approach focused on preventing and managing reperfusion pulmonary edema, right ventricular dysfunction, and other complications.
Immediate Post-Operative Care
Respiratory Management
- Monitor for reperfusion pulmonary edema, a potentially fatal complication that can develop within hours to days after surgery
- Use non-invasive ventilation or high-flow oxygen therapy for patients developing hypoxemia or respiratory distress 1
- Consider early implementation of venovenous extracorporeal life support (V-V ECLS) for severe reperfusion edema not responding to conventional therapy, ideally within 120 hours of surgery 2
- Maintain protective ventilation strategies:
- Tidal volumes of 6-8 mL/kg ideal body weight
- Appropriate PEEP (8-10 cmH₂O)
- Regular recruitment maneuvers
Hemodynamic Monitoring
- Continuous invasive arterial pressure monitoring
- Central venous pressure monitoring
- Consider pulmonary artery catheter for the first 24-48 hours to:
- Monitor pulmonary vascular resistance (PVR)
- Assess right ventricular function
- Guide fluid management
- Target PVR reduction to <400 dyn·s⁻¹·cm⁻⁵ within 48 hours after surgery 3
Fluid Management
- Maintain euvolemia with careful fluid balance
- Avoid excessive fluid administration which may worsen reperfusion edema
- Use balanced crystalloid solutions
Specific Complications Management
Reperfusion Pulmonary Edema
- Most common serious complication after pulmonary endarterectomy
- Management:
- Optimize oxygenation with appropriate ventilatory support
- Judicious fluid management
- Consider diuretics if fluid overload present
- Pulmonary vasodilators (inhaled nitric oxide) may be beneficial
- V-V ECLS for severe cases 2
Right Ventricular Dysfunction
- Monitor for signs of right heart failure
- Management:
- Optimize preload
- Inotropic support (dobutamine, milrinone)
- Pulmonary vasodilators to reduce RV afterload
- Avoid systemic hypotension
Anticoagulation
- Lifelong anticoagulation with warfarin targeted to an INR of 2-3 is recommended 1
- Begin anticoagulation as soon as postoperative bleeding risk is acceptable
Post-ICU Management
Mobilization and Physiotherapy
- Implement early mobilization as part of enhanced recovery protocol 1
- Provide multimodal postoperative physiotherapy including:
- Early ambulation
- Breathing exercises
- Incremental strengthening exercises 1
Pain Management
- Multimodal analgesia to facilitate respiratory effort and early mobilization
- Consider thoracic epidural if no contraindications
- Non-opioid analgesics (acetaminophen, NSAIDs) as first-line therapy
Discharge Planning and Follow-up
Monitoring Before Discharge
- Assess hemodynamic improvement with echocardiography
- Evaluate functional status (6-minute walk test when appropriate)
- Ensure adequate oxygenation without supplemental oxygen
Long-term Follow-up
- Schedule follow-up at 3 months, 6 months, and annually thereafter
- Monitor for:
- Recurrent pulmonary hypertension
- Right ventricular function
- Functional capacity
- Anticoagulation management
Prognostic Considerations
- Expect significant clinical improvement in most patients
- Long-term survival after successful pulmonary endarterectomy is excellent (75-92% at 6 years) 1
- 93% of patients achieve NYHA functional class I or II after surgery 1
- Predictors of better outcomes include:
- Male gender
- Lower preoperative mean pulmonary arterial pressure
- Greater number of desobliterated segments 3
Common Pitfalls and Caveats
- Delayed recognition of reperfusion pulmonary edema - Monitor closely for the first 72 hours when risk is highest
- Inadequate anticoagulation - Ensure appropriate bridging to warfarin therapy
- Overlooking right ventricular dysfunction - Continue monitoring RV function even after initial hemodynamic improvement
- Delayed mobilization - Implement early physiotherapy to prevent complications
- Failure to identify patients needing V-V ECLS - Early implementation (within 120 hours) is associated with better survival 2
By following this comprehensive approach to post-operative management after pulmonary endarterectomy, clinicians can optimize outcomes, reduce complications, and improve long-term survival and quality of life for these complex patients.