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NEWSMAKER Nicholas Smedira, M.D., Cardiothoracic Surgeon, Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic

Community recently spoke with Nicholas Smedira, M.D., cardiothoracic surgeon at Cleveland Clinic’s Department of Thoracic and Cardiovascular Surgery, about pulmonary thromboendarterectomy (PTE) as a treatment for chronic thromboembolic pulmonary hypertension (CTEPH).

When did Cleveland Clinic first start doing PTE, and what are some of the advances that have been made in the procedure? When I arrived here, 20 years ago, the surgeons were already doing acute and chronic pulmonary emboli treatments in the operating room, so definitely 20-plus years.

What are some of the biggest challenges for the surgery and the biggest potential risks for patients, and how do you overcome those challenges? One is that the arteries, beyond where the clots have lodged, have been damaged and become thickened, such that, even when taking the clot and scar out, they still have residual pulmonary hypertension. So, we go through great efforts, using CT scan, angiography, and other modalities, to make sure that the extraction of the material will improve the pulmonary hypertension. That’s probably our greatest challenge. The two things that can happen during surgery are that the lung tissue, beyond

Above: Miller Family Pavilion, Cleveland Clinic, Cleveland, Ohio

The surgical technique has remained more or less the same for the last twenty years. The biggest improvements have been in the supportive care of the patients before, during, and after the operation, protecting their lungs, their brain, and their kidneys from any damage from the stress of the surgery. The biggest strides have been in helping patients recover. 12

where the blockages have been, all of the sudden see new, excessive blood flow, and they can develop some edema. It’s called reperfusion pulmonary edema (RPE), and that happens in maybe about 10 to 15 percent of cases. Finally, the conduct of the operation requires us to cool the patient’s body, and for periods of time, stop the circulation, so • Winter 2014 • Traveling for Treatment Issue

there’s no blood circulating in the body — that’s called circulatory arrest, and we again go through great efforts to protect the brain, so that there’s no damage to the brain, so that there’s no stroke. Succinctly, the three things we think about are residual pulmonary hypertension, injury to the lung after the scar has been removed, and some sort of brain injury.

Are there other protections involved? We give medications, steroids, and certain drugs to protect the brain. We monitor the brain activity, but cooling is the predominant mechanism. What sort of benefits have you seen with successful surgery? If you get all the material out, and there’s been no downstream thickening of the arteries, patients’ pulmonary artery pressures return to normal. You can’t tell the difference between a healthy person and someone who’s had this operation. Their exercise capacity and functional capacity return to normal. Their right ventricle that has been under strain returns to normal. So, it’s a curative operation, when there’s been no downstream damage to the pulmonary vessels.

Is the damage something that you know about before the surgery? Sometimes the angiogram will give you a hint that there’s a problem — when you don’t really see a lot of obstruction or material in the arteries, but their pressures are very high, suggesting that this is small vessel, rather than large vessel disease. But some patients have a combination of both, and they have a lot of material in the arteries, and so you think, well, boy, there’s a large volume of material to get out, but they’ve also developed downstream damage, and it can be hard to differentiate. If you don’t see a lot of material and you have high pressures, you surmise that

COMMUNITY Magazine, Winter 2014 - Travelling for Treatment  
COMMUNITY Magazine, Winter 2014 - Travelling for Treatment  

Caring Voice Coalition's Winter 2014 issue of Community Magazine.