353

Early and Late Results after Surgery for Massive Pulmonary Embolism E. P. Bauer. A. Laske. L. K. von Seqesser, T. Carrel. and M. l. Turin a Clinic for Cardiovascular Surgery. University Hospital Zurich. Switzerland

Between 1978 and 1990 emerge ncy pulmonary embolectomy with th e aid of extraco rpo rea l circulatio n (ECC) was performed for massive pulm onary embolism (PE) in 44 patients (19-73 yrs: 49 ± 15yrs). Cardiopulmonary circulation was stable in 16/ 44 patient s but uns tabl e in 28/44 ; of th e latter . 15 had und ergone previous cardiopulmona ry resus citati on due to cardiac arrest. Diagno sis of PE was obtained clinically in 15/44 patients. by angiogra phy in 13/44 . by echocardiography in 10/44 . and by perfusion scintigraphy of the lung in 6/ 44 patients. Ther e were 9/ 44 (20%) postoperative deaths. Early morta lity was significantly higher in previously resus citated patients (p < 0.05). There were 2/36 (6 %) late death s. Actuari al survival was 75 % after 4 yrs and 71 % after 8 yrs . 77 % or 35 survivors were in NYHA-class I and 23 % in NYHA-class II after a mean follow-up of 4.6 yrs . Pulmonary embolectomy is indicat ed in patients with central PE and shock; it is advisa ble in patients with embolism of the main pulmonary artery or its major bra nches or in patients with contraindication to thrombolysis. Intr aoperative inserti on of a vena cava filter is recomm end ed for prevention of recurrent embolism. Preoperative resuscitation and duration of ECC are predictors for early death . Keywords

Friih- und Spiitergebnlsse nach chirurgischer Behandlung der massiven Lungenembolie Zwischen 1978 und 1990 worden 44 Patient en (l 9-7 3jiihrig; 49 ± 15J .) wegen einer massiven Lungenemb olie (LE) notfallmiiBig mit der Herzlungenm aschine operiert . Insgesam t waren 16/44 Patient en kreislau fmiiBig stabil und 28/44 instabil ; von den instabilen Patienten muBten 15/ 44 priioper ativ wegen eines Herz-Kreislaufstillstand es reanimi ert werd en . Die Diagnose der Lungenembolie wurde bei 15/44 Patient en klinisch gestellt, bei 13/44 angtogra phtsch, bei 10/44 echokardiographis ch und bei 6/ 44 szintigraphisch. Postoperativ starben 9/ 44 (20 %) Patient en . Die Friihmortalitiit war signifikant hoher bei vorgiingig reanimiert en Patient en (p < 0.05). 1m Spatver lauf starb en 2/ 36 (6%) Patienten . Die aktua rielle Oberlebensquote betrug 75 % nach 4 Ja hren und 71 % nach 8 Jahren . 77 % der Uberlebenden ware n in NYHA-Klasse lund 23 % in NYHAKlasse II nach einer mittleren Beobachtun gszeit von 4,6 Jahren. Die Embolektomie der Pulmonalarteri en ist ind iziert bel Patienten mit zentraler LE und Schock; die Operation wird angest rebt bei Patient en mit einer Embolie der Hauptstiimme und deren groBen Seitenaste , oder bei Pat ient en mit eine r Kontraindikation fiir die Thrombolyse. Die int raoperat ive Einlegong eines Vena-cava-Filters wird empfohlen zur Verhinderung weiterer Embolien .

Pulmonary embolism - Surgery

Introduction The mana gement of a cute m a ssi ve pulmon a ry em bo lism (PEl still remains a co ntro ve r sial issue . After the in troduction of thrombolytic agents for the co nservative treatment of pulmonary em b olis m. emergen cy pulmonary em b olec tomy is no longer con sider ed the optimal therapy under all cir cu m stances by most clinicians (11. 14, 19. 20 ). Some a uth or s still b eli ev e that pulmonary em bo lec to m y is justifi ed eve n prophylactically (2.4) . At the other extreme so me b eli ev e that em b olec to m y is only indicated under sp ecial circumstances . such a s patient in shock or with occl us ion of one o r both pulmonary arteries (9.1 3). When thrombolysi s is co n tr a in d ica te d most authors agree that su rgical removal of pulmona ry em b oli should b e performed. The present study des cribes ea rl y an d late r esults a fte r o pe n pulmona ry em bo le cto my in patients with m a ssive PE a n d s hock. in

Thorac. cardiovasc. Surgeon 39 (1991) 353-3 56 © Georg Thieme Verlag Stuttgart · New York

p atients wi th oc clus ion of one o r both pulmonary a rter ie s, a n d patients wi th co n tra in dication to thrombolysis. Material and Methods Between February 1978 and Janu ary 1990 a total of 44 patients und erwent emergency pulmonary embolectomy with extra corporeal circulation at our hospit al. There wer e 24 males and 20 femal es with an aver age age of 49 ± 15 yea rs (range 19-73 years) . Cardio-pulmona ry circulation was stable in 16/44 (36 %) patients but was unstabl e (cardi ac arrest, or systolic blood pr essure < 80 mmHg despite administra tion of catech olamines) in 28/ 44 (64 %); in th e latter group 15/44 (34%) had und er gone previous cardio-pulmonary resuscitation due to cardiac arrest. In patients with sta ble card io-pulmonary circulation the indication for opera tion was given by th e occlusion of one or both pulmonary arte ries in 13 cases and/o r by contraindication to thrombolysis in 7 cases (recent tra uma in 3. recent operation in 4). Diagn osis of PE was

Received for Publication: May 21 . 1991

Downloaded by: University of Pennsylvania Libraries. Copyrighted material.

Summary

Thorac. cardiouasc. Surgeon 39 (1991)

obtaine d clinically in 15/44 (34 %) patients; it was verified by pulmonary angiography in 13/44 (29%), by echocardiography in 10/ 44 (23 %) and by perfusion szintigraph y in 6/ 44 (14 %) patients . Patient characte ristics are listed in Table 1. Surgical techniqu e: The heart was exposed thr ough median sterno tomy followed by cannulation ofthe ascending aorta, inferior and superior V. cava, or right atrium; normotherm ic bypass was initiated. After electrical induction of ventricular fibrillation the main pulmonary artery was opene d and clots removed with a special forceps. Revison of right atrium and ventricle and closure of arte riotomy was now perform ed. A V. cava filter was inserted through the right atrium. A pump-oxygenator was used to support the recovery of right ventricular function. Arterial and venous cannulae were removed and sternoto my closed. Follow-up data were obtained by means of questionair es sent to referrin g physicians . Mean follow-up time was 4.6 years (2 month s to 13 years). Comparison of categorical varia bles between groups was perform ed using the Fischer's exact-test. The cumulative survival curves were calculated using the actuarial method of Kaplan and Meier. The level of significan ce was chosen as 0.05 (ns: non significant).

Result s There were 9/44 (20 %) ea rly deaths. Data of patients who died within 30 days afte r ope ration are listed in Tab le 2. Early death occurred in 3 patients du e to low cardiac output. Intractable bleeding and sepsis caused death in another 3 and 2 pati ents, respectively. One patient died of severe strok e. A total of 12 early complications occurred in the 9 pati ents (neurologic in 4, cardiac in 3, bleeding in 3 and sepsis in 2 cases). Autopsy of 7 of the 9 pati ents revealed myocardial necrosis in 6 cases, cere bral infarction or ede ma in 3, recurrent pulmonary embolism in 3, hemorrhagic erosions of gastrointestinal tra ct in 2, and cancer (prostate, kidn ey, lung) in 3 cases. Two pati ents died within hours after ope ra tion, whereas the oth ers died between 1 and 19 days after surgery . In patients with stable cardiopulmonary cir culation pri or to surgery th er e were 15/1 6 (94 %) survivors, wh er eas 20/2 8 (71 %) pati ents with uns tabl e circulation survived th e operation (ns). Ofthe 15 patients, wh o had undergone ca rdio-pulmo nary resuscitati on du e to ca rdiac arrest 7/15 (47 %) died , in contra st to only 2/29 (7%) pati ents with out cardio-pulm onary resus citation (p < 0.05). Earl y death occurred in 2/25 (8%) pati ents under 50 years of age and in 7/19 (37 %) pati ents older than 50 years (ns), Mean bypass-time was 61 minutes. Ofth e 32 pati ents with bypass-time und er 60 minutes 4 (12 %) died, in contrast to 5 of 12 (42 %) pati ent s with bypass-tim e over 60 minutes (p < 0.05) . Late death occurred in 2 of th e 35 early survivors. The re was one accidental death 2 years afte r opera tion; another patient died of unknown reasons 6 years afte r pulmonary embolectomy. Actuarial survival (includ ing operative mortality) was 74 % afte r 4 yea rs (95 % confidenc e limits [CLl 62-89 %) and 71 % afte r 8 years (CL 56-86 %) (Fig. 1). Follow-up information was obtained in 32/35 (91 %) survivors after a mean tim e of 4.6 years. 77 % of all patients were in functional class I and 23 % in class II according to the New York Heart Association (NYHA). Two pati ents had persistent hemiplegia after operation; one pati ent experience d recurrent peripheral pulm onary embolism . In this pati ent inserti on of a vena cava filter was not possible due to techni cal problems at the time of ope ration.

E. P. Bauer. A. Lask e. L. K. uon Segess er, T. Carrel, and M. I. Turina Table 1 Medical history in patients with massive pulmonary embolism (n ~ 44: UHZ 1978-1990)

n

recurrentPE oral contraceptives viralinfection venous thrombosis recenllrauma recentsurgery noinformation

Table 2

No

stable

58

recent surgery recent surgery

m,

recurr.

61

PE recent trauma

m, f, 45

m, 66

5

m, 64

6 7 9

f,

m, 35

PE

Data ofpatientswho died within 30 daysafter operation

cardiac massage cardiac massage cardiac massage unstable

73

4

4

re curr, PE,DVT recent surgery recent surgery recent surgery

m,

3

13

sex, history preop. age state 55

2

6 2 8 11 9

=

cardiac massage cardiac massage cardiac massage

early complications

autopsyfindings

g.i. bleeding

recurrent PE, hemorhagic colitis prostate Ca,MI, pneumonia Mi, injury PA

anuria, sepsiscoma lung bleeding embolismrenalar· tery, biventricular heart failure stroke, g.i. - bleed· ing brain death biventricular heart failure sepsis, coma

kidneyCa, MI cerebral infarction no autopsy lungCa, MI recurrent PE myocarditis cerebral infarction recurrent PE

pulmonaryembolism

DVT ~ deepvenous thrombosis

Ca PA g.i MI

cancer pulmonary artery = gastrointestinal ~ myocardial infarction ~

~

Discuss ion There is much controversy ab out the tr eatment of choice for massive pulmon ary embolism , du e to th e fact that th er e a re no large randomis ed trials as it is unethical to refus e surgery in hemodynamic ally compromised patients. Sautter et al. (19) have concluded from th eir data that there are no indications for the eme rgency operations . One can a rgue that patients who would profit most from a surgical int erv ention seldom reach the hosp ita l alive. Patien ts who surviv e thrombolytic therapy long enough have in most instances good results (1). In contrast Berger et al. (2) consider even prophylactic open embolectomy to be justified in patients with massive pulmonary embolisation. This may be true if large mobil e emboli es are present either in th e right heart or in the main pulmonary artery. Under these conditions thrombolytic th erapy could be even fata l du e to distal embolisation of clots into th e main pulmonary artery (4). There are also clinical situations in whi ch pati ents are too ill to receive thromb olytic therapy (8, 17). Thus, it app ears reas onable to conside r surgi cal embolectomy for pati ents with massive pulmonary embolism and marked hypoten sion who requires vasopressor therapy or for pati ents with severe persisting hypoxia (14,16,18). In our seri es 64 % of

Downloaded by: University of Pennsylvania Libraries. Copyrighted material.

354

Early and Late Results after Surgeryfor Massive Pulmonary Embolism

Thorac. cardiavase. Surgeon 39 (1991)

0/0 survival 100

.- - - - -. - - - - - -. - - -- - -. -

-

.

-

- -

.. -

~

-

- --- . - -.

e

~

__ ._ •

•

355

Fig. 1 Actuarialsurvival after surgeryofmassive pulmonary embolism(no. patients operated on: 44;squared pointsdenote 95 %confidence limits). Thenumbers inparenthesisare the numbers of traced patient at each follow-up period.

80

60

.--- - -- -.- - - - - - __ e __ -

- - - - _e - - - - - - - - - ~

(30)

(23)

(19)

(16)

(16)

.. - ---- --- .. - -- ---.- - -.- - --.

( 16 )

(16 )

( 13 )

(11 )

40

2

3

4

5

7

6

years

all pati ents presented with an unstable cardiopulmonary circulation with signs of shock despite administration of catecholamines. In patients with contr aindications for thrombolytic therapy surgical removal of massive pulmonary embolies is warranted (8, 12). In 16 % of our patients a recent trauma or previous surgery 3 to 10 days before the onset of pulmonary embolism excluded thrombolysis for tr eatm ent of pulmonary embolisation . Hemodynamic deterioration during thrombolysis requir es also immediat e embolectomy; however this clinical situation was not observed in the present series of patients (8,12 ,17). The diagnosis of pulmonary embolism is usually made on clinical grounds. Today, bedside echocardiography allows the diagnosis to be confirmed even in very ill patients (3). Angiography is the most appropriate method to diagnose central pulmonary embolism and should be carried out in all uncertain cases; nevertheless this examination is only possible in patients with stabl e cardiopulmonary circulation 12 . 15). It is obvious that pulmonary embolectomy should be performed today with the aid of extra corporeal circulation (2). This technique allows a thorough revision of the right atrium, right ventricle, and the pulmonary artery. In a review of Del Campo and coworkers (6) overall survival in 109 patients operated without extracorporeal circulation was 48 % compared to 59 % in 526 patients treated with the aid of a pump oxygenator. When no pump oxygenator is availabl e, pulmonary embolectomy can be performed with the technique of inflow occlusion (9). Survival after pulmonary embolectomy for massive pulmonary embolism is depend ent on the preoperative hemod ynamic stat e. When the patients has been resus citated prior to surgery early mortality varies in larger series between 64 % and 84 % compared to 11 %- 22% in patients without resuscitation (5, 7, 9). This is in accord with our results of 47 % and 7 % respecti vely. Age of the patient was also a factor influencing periop erativ e mort ality; nevertheless, in our stud y this difference was statisti cally not significant. Long support with the pump-ox ygenator was necessary in patients with sever e right heart failure. Thus , mortalit y in patients with bypass-

duration over 60 minut es was higher due to persistent right or biventricular pump insufficiency. There ar e a few studies dealing with long-term followup results after pulmonary embolectomy. Lund et al. (10) observed that patients after pulmonary embolectomy wer e in a more favorabl e NYHA-class compared to medically tr eated patients . M eyer et al. (13) could demonstrate that 39/ 55 (71 %) survivors after pulmonary embolectomy showed no signs of cardiac or pulmonary functionallimitation and 16/ 55 (29 %) complained of exertionaI dyspnoe. In our series, 77% of all patients were in NYHA-class I after a mean follow-up time of 4.6 years.

References 1

2 3 4

5 6 7

8

9

10

II

A lpe rt. J. S , R. E. Smith, I. S Ockene, J. Ask ena zi, L. Dexter, and J. E. Dalen: Tre atme nt of mas sive pulmonary embolism: th e role of pulm onary embolectomy. Am. Heart J. 89 (197 5) 41 3-41 8 Berger, R. L. : Pulmonary embolectomy with preoperative circulatory support. Ann. Thora c. Surg. 16 (197 3) 217-227 Bloomfi eld, P.. N. A. Boon, and D. P. De Bono: Indicati ons for pulm onary embolectomy. La ncet 6 (1988) 329 Busch, U', A. Wirtzfeld, H. Sebeninq, F. Se beninq. und H. Bliimer: Embolektomie bei Pati ent en mit Lungen emb olie ohne Sch ocksymptomatik . Klin. Wochens chr. 62 (1984) 724-727 Clarke, D. B., a nd L. D.A brams: Pulmonary embolectomy: a 25 year experience . J. Thorac . Cardiovasc. Surg. 92 (1986) 442-445 Del Campo, C: Pulmon a ry embolectomy: a review. Can. J. Surg . 28 (1985) 111-11 3 Giraud, C.. J. Laquere, A. Cerene, and P. Puel: L'assistance circula toire s'impose -t-elle dan s Ie traiteme nt chirur gical de l'e mbolie pulmonair e mas sive aigue? Ann. Chir. Chir . thorac. cardiovasc. 38 (1984) 572-5 76 Gray, H. H.. G. A. Miller, and M. Paneth: Pulmonary embolectomy: its place in the man agem ent of pulmona ry embolism. Lan cet 25 (1988) 1441-1445 Gray, H. H., J. M. Morgen, M. Paneth, and C. A . Mill er: Pulmona ry embolectomy for acute massive pulmona ry embolism : a n analysis of7 1 cases. Br. Heart J . 60 (1988) 196 -200 Lund, 0.. T T Nilse n, K. Ronn e. a nd S. Schifter: Pulmonary embolism : long term follow-up after treatmen t with full-dose hep arin, stre ptokina se or embolectomy. Acta Med. Scand . 22 1 (1987) 61-71 Ly. B.. H. Arnesen. H. Hie, and R. Hal: A controlled clinical tri al of

Downloaded by: University of Pennsylvania Libraries. Copyrighted material.

20

Thorae. eardiovase. Surgeon 39 (1991)

12

13

14

15

16

17

streptokinase and heparin in the treatment of major pulmonary embolism. Acta Med. Scand . 203 (1978) 465-470 Masters. R. G.. A. Kosha l. L. A. Higginson. and W J. Keon: Ongoing role of pulmonary embolectomy. Can. J. Cardiol. 4 (1988) 347-351 Meyer. G.. D. Tamisier, H. Sors , M. Stern. P. Vouhe, S. Makowski. J. Y. Neue ux, F. Leca, and P. Even : Pulmonary embo lectomy: a 20-year experience at one center . Ann. Thorac. Surg . 51 (1991) 232-236 Miller. G. A. H.. G. C. Sutton. I. H. Kerr. R. V. Gibson. and M. Honey : Compa rison of streptokinase and heparin in the treatment of isolated acute mass ive pulmonary embolism . Br. Med. J. 2 (1971) 681-684 Mohr. D. N.. J. H. Ryu. S. C. Litin , and E. C. Rosenow: Recent adva nces in the ma nagement of venous thromboembolism . Mayo Clinic. Proc. 63 (l988) 281-290 Robinson. R. J.. J. Fehrenbacher. J. W Brown. 1. A. Madura. and H. King: Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus. Ann . Thorac. Surg. 42 (1986) 52-55 Rosenthal. D.. D. R. Evans. E. Borrereo, P. A. Lamis, M. D. Clark. and W. W. Daniel: Massive pulmonary embolism: triple-armed therapy. J. VascoSurg. 9 (1989) 261 -270

E. P. Bauer. A . Laske. L. K. von Seqesser, T. Carre l. and M . I. Turina 18 19

20

Sasahara, A. A.. E. M. Barsamian: Another look at pulmonary embolectomy. Ann. Thorac . Surg. 16 (1973) 317-3 20 Sauter. R. D.. W O. Myers. J. FRay Ill, and F J. Wenzel: Pulmonary embolectomy: review and current status. Prog. Cardiovasc. Dis. 17 (1975) 371-389 Tibbut, D. A.. J. A. Davies. J. A . Anderson et al.: Comparison by contro lled tria l of streptokinase and hepa rin in treatment of lifethr eatening pulmonary embolism. Br. Med. J. I (1974) 343-347

Dr. E. P. Bau er

Clinic for Cardiovascu lar Surgery University Hospital Ramistralle 100 CH-8091 Ziirich Switzerland

Downloaded by: University of Pennsylvania Libraries. Copyrighted material.

356