P-236THORACOTOMY IS A PAIN RELIEVING STRATEGY IN THE ABSENCE OF A PULMONARY ARTERY

Abstract

Objectives: The specialist pain services referred a 26-year old lady with chronic intractable right chest pain. She had been through a significant spectrum of therapies including a methadone trial. No therapy was successful and implantable stimulators were under consideration. She was referred for surgical advice. Case description: On assessment with a computed tomography scan of the thorax, the patient was found to have a congenitally absent right pulmonary artery and a hypoplastic right lung. She had moderate bronchiectasis, but did report repeated chest infections and haemoptysis. She reported dyspnoea at rest and on exertion and in addition, she desaturated on a walk test (88%). This had prompted her to be placed on continuous home oxygen 2 years prior to referral and she was on 2-5 l at the time of referral. A thorough assessment was performed in conjunction with the cystic fibrosis group. No additional congenital abnormalities were identified. Her VQ scan showed 94% perfusion of her left lung and 54% ventilation. She had a number of major arteriopulmonary collateral arteries (MAPCAs) to the right side. She was assessed over a 3-month period, during which intensive bronchiectasis therapy improved her condition and reduced her oxygen requirement. After deliberation she proceeded to pneumonectomy. A right pneumonectomy was performed by an open thoracotomy approach. The procedure was well-tolerated and she was discharged without complication. On follow-up she has stopped all pain medications, is no longer using supplementary oxygen and now attending college. Conclusions: Chest pain is observed in cases with sequestrations and congenital absence of a pulmonary artery with a hypoplastic lung. The pain often resolves with resection. The mechanism by which this occurs is not clear. In this case, bronchiectasis and haemoptysis were also of concern and in this case, the patient experienced an improvement in pulmonary performance, which may be related to pain optimization or surgical management of bronchiectasis.