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Introduction

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Bronchogenic carcinoma remains the most common cause of cancer death in both men and women in the United States. These tumors can exhibit local progression and invasion before metastatic spread has occurred, which does not preclude resection with curative intent. Any contiguous structure within the chest may be involved, with chest wall involvement being the most common. Other potential sites of local invasion include the left atrium, aorta, superior vena cava, vertebral bodies, diaphragm, and esophagus. The increased potential for morbidity and mortality are well documented for these complex extended resections, making appropriate patient selection crucial. Long-term prognosis depends on accurate pretreatment staging to assist in selection of therapy and complete resection. Cardiopulmonary bypass (CPB) may be necessary to allow surgical resection of central, locally advanced malignancies because they involve, or are close to, the heart and/or the great vessels. CPB serves as an alternative to conventional ventilation during extended resections providing oxygenation and hemodynamic support. This chapter will review the role of CPB for the extended resection of lung cancer, as well as the clinical and technical considerations and expected surgical outcomes.

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General Principles

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For those patients presenting with locally advanced lung cancers, long-term outcome is primarily dependent on the ability to obtain a complete (R0) resection. For non–small-cell lung cancers (NSCLCs) with direct invasion into the mediastinum, Martini et al.1 found a survival rate of 30% if an R0 resection was obtained in contrast to 14% if the resection was incomplete. Likewise, for tumors invading the heart or the great vessels, 5-year survival rate ranges between 23% and 40% with complete resection versus 0% with incomplete resection.2,3

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The operative approach is ultimately based on the tumor anatomy, the need for vascular reconstruction, and the urgency with which circulatory support is initiated. To optimize outcomes, one must maintain a flexible strategy with regard to arterial and venous cannulation sites, need for aortic clamping, cardioplegia requirements, and deairing options.

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When an injury to a major vascular structure (i.e., pulmonary artery, superior vena cava) occurs during a thoracotomy, CPB support may be required. In the setting of a right thoracotomy approach, cannulation can be achieved via the ascending aorta and the right atrium. In the setting of a left thoracotomy approach, cannulation can be obtained via the descending thoracic aorta and main pulmonary artery.4

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If the groin is accessible, systemic venous drainage can be achieved by placing a long venous cannula into the right atrium through the femoral vein. In the emergent setting, decompression of the heart with the ability to control blood loss and return shed blood is usually all that is required to enable primary or patch repair of the injury to the central vascular structure.

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In the elective setting, standard median sternotomy is the surgical approach used to address lesions involving the central pulmonary arterial system. ...

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