Management of airway hemorrhage in patients undergoing pulmonary endarterectomy – an expert center experience and modification of procedures: a case report

Background: Pulmonary endarterectomy is an established treatment for selected patients with chronic thromboembolic pulmonary hypertension. And bleeding into the airways is a feared complication of this surgical technique. Although its incidence is relatively low (0.4–6%), its mortality rate remains very high (>50%). Its current management involves isolating the source of bleeding with a bronchial blocker or, if necessary, using a double-lumen endotracheal tube. In our case, we describe the use of endobronchial valve instead of blocker to treat source of bleeding. The procedure we chose has not yet been described in the literature. Case presentation: A 55-year-old man with chronic thromboembolic pulmonary hypertension underwent PEA during a 41-minute deep hypothermic cardiac arrest. During normothermia, prior to disconnection from the cardiopulmonary bypass, blood was detected in the endotracheal tube. Approximately 800 ml of fresh blood was aspirated from the endotracheal tube. The patient was connected to central veno arterial extracorporeal circulation, and his coagulation was normalised. The summoned pneumologist detected the source of bleeding in the right B2 segment, where one endobronchial valve was implanted. No further bleeding occurred, and after 122 minutes of mechanical support, the device was disconnected, the surgery was concluded, and the patient was transferred to the postoperative intensive care unit. Heparinization was initiated soon after surgery. The patient was on artificial ventilation until the first postoperative day. The valve was later removed by the pneumologist under topical anaesthesia with sedation in a short heparin-free window. Conclusion: Compared to standardly used bronchial blockers, the use of endobronchial valves may offer several advantages that, if confirmed by randomised studies, could contribute to improving morbidity and mortality in this feared complication. Specifically, this involves reducing the risk of dislocation of the device that closes the treated bronchial segment, shortening the duration of artificial ventilation, and finally, earlier initiation of postoperative anticoagulant therapy.