Original Research Received: March 17, 2014 Accepted after revision: May 11, 2014 Published online: September 10, 2014
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism Berhane Worku a, b Iosif Gulkarov a, b Leonard N. Girardi a Arash Salemi a
a
Department of Cardiothoracic Surgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, N.Y., and b Department of Cardiothoracic Surgery, New York Methodist Hospital, Brooklyn, N.Y., USA
Abstract Objectives: Significant improvements in outcomes after pulmonary embolectomy have resulted in a broadening of indications. We reviewed our experience with pulmonary embolectomy over the past 12 years with an emphasis on preoperative comorbidities and postoperative morbidity and mortality. Methods: All patients undergoing pulmonary embolectomy over the past 12 years at our institution were analyzed via retrospective chart review. Data on preoperative characteristics, operative procedures and postoperative outcomes were collected. Results: Twenty patients underwent pulmonary embolectomy between 1999 and 2011. The average age was 56 years (range 24–81) and 10 patients (50%) were female. All patients demonstrated right ventricular dysfunction and 19 (95%) demonstrated contraindications to thrombolysis. Twelve patients (60%) demonstrated intermittent hypotension, 4 (20%) required intubation and 3 (15%) demonstrated preoperative or intraoperative cardiac arrest. Survival to discharge was 95%. Conclusions: Pulmonary embolectomy has been shown to be safe and effective in the treatment of massive pulmonary embolism (PE). We achieved a 95% survival rate in a cohort of patients with sig-
© 2014 S. Karger AG, Basel 0008–6312/14/1292–0106$39.50/0 E-Mail [email protected] www.karger.com/crd
nificant comorbid status. Pulmonary embolectomy should be considered early in the therapeutic algorithm for patients with submassive PE presenting with right ventricular dysfunction to prevent progression. It can also be performed with good outcomes in those already suffering hemodynamic compromise. © 2014 S. Karger AG, Basel
Introduction
Pulmonary embolism (PE) can present with a wide range of severity. Milder forms may be asymptomatic and are adequately treated with anticoagulation alone. Acute massive PE presenting with respiratory and hemodynamic collapse and shock is a highly lethal event requiring more aggressive treatment, usually including surgical pulmonary embolectomy. The treatment of submassive PE presenting with stable hemodynamics in the setting of right ventricular strain on echocardiography [1, 2] or computed tomography (CT) scanning [3] has been more controversial. Strategies include thrombolysis, catheter embolectomy and surgical pulmonary embolectomy. In recent years as the outcomes for surgical embolectomy have improved, the range of indications has broadened, and some groups now consider it the treatment of choice for submassive PE [1, 4–6]. We reviewed our experience Berhane Worku 525 East 68th St M525 New York, NY 10021 (USA) E-Mail bmworku @ hotmail.com
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Key Words Pulmonary embolism · Embolectomy · Deep vein thrombosis
Materials and Methods A retrospective review of hospital records of all patients who underwent pulmonary embolectomy at our institution over the past 12 years was performed. Data collected included demographic variables, presenting characteristics, risk factors, diagnostic imaging modalities, hemodynamic and respiratory status, operative procedures, operative times, postoperative complications and anticoagulation protocols. This study was conducted in accordance with the amended Declaration of Helsinki. From June 1999 to October 2011, 20 patients underwent pulmonary embolectomy at our institution. The average age was 56 years (range 24–81) and 10 patients (50%) were female. All patients underwent CT scanning for the diagnosis of PE, and 17 (85%) underwent transthoracic or transesophageal echocardiogram for the assessment of ventricular function. Right ventricular dysfunction was considered present in the setting of right ventricular dilation, decreased contractility or tricuspid regurgitation. The presence of deep vein thrombosis (DVT) was assessed by CT scanning and/or venous duplex scanning. Surgical Technique Median sternotomy was performed in all cases. Arterial cannulation was performed via the ascending aorta, and venous cannulation was performed via a single cannula in the right atrium or via bicaval cannulation, depending on the need for right atrial exploration (e.g. a clot in transit or patent foramen ovale). All cases were performed on full cardiopulmonary bypass with mild hypothermia. Aortic cross-clamping with cold potassium cardioplegia arrest and circulatory arrest were utilized at the surgeon’s discretion and based on the need for associated procedures. The main pulmonary artery was incised and all clots were extracted with forceps, Fogarty catheters and flushing. In 3 patients, the right pulmonary artery was explored separately via an incision between the aorta and the superior vena cava to extract more distal clot. Patients were weaned from cardiopulmonary bypass with the use of inotropes, vasopressors and intra-aortic balloon pump assistance as necessary.
Results
From June 1999 to October 2011, 20 patients underwent pulmonary embolectomy at our institution, with 9 (45%) having been transferred from an outside institution. Symptoms and signs included dyspnea, with 4 patients requiring intubation, chest pain, altered mental status, syncope, tachycardia, and hypotension, with 3 patients suffering cardiac arrest. Two patients with known caval and right atrial tumor thrombus, due to chrondroma and renal cell carcinoma, respectively, underwent Pulmonary Embolectomy
Table 1. Demographics and presenting characteristics
n (%)1 Age, years Female Transfer from outside hospital Symptoms/signs Dyspnea Intubation Altered mental status Syncope Chest pain Tachycardia Hypotension Cardiac arrest 1
56 (24 – 81) 10 (50) 9 (45) 16 (80) 4 (20) 1 (5) 4 (20) 4 (20) 13 (65) 12 (60) 3 (15)
Unless otherwise indicated.
Table 2. Risk factors for development of PE
n (%) Recent surgery Orthopedic Neurosurgical Vascular Cardiac Thoracic Gynecological Neoplasia Immobility Previous PE
11 (55) 6 (30) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 7 (35) 9 (45) 2 (10)
elective surgery for tumor thrombus extraction under circulatory arrest. One of them developed a large PE intraoperatively, which required emergency cardiopulmonary bypass. One patient had suffered multisystem trauma in another country several days before, which had resulted in paraplegia. She was transferred to our institution, where, after stabilization of her orthopedic injuries, she underwent prophylactic inferior vena cava filter placement. Massive PE occurred during the procedure and an emergency pulmonary embolectomy was performed. Demographics and presenting characteristics are outlined in table 1. Risk factors for the development of PE included recent surgery, active cancer, immobility and previous DVT/PE (table 2). Surgical procedures occurred within an average of 17.3 days prior to the development of PE. Five patients had a history of immobility secondary to recent orthopeCardiology 2014;129:106–110 DOI: 10.1159/000363647
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with pulmonary embolectomy over the past 12 years, with an emphasis on presenting characteristics, indications for surgery, operative findings and outcomes.
n (%) Recent surgery (thrombolysis contraindicated) Clot in transit Right atrial clot suspected Paradoxical clot in transit Aortic thrombus Hemodynamic instability/preoperative arrest
9 (45) 13 (65) 9 (45) 3 (15) 1 (5) 13 (65)
dic procedures, 2 due to a history of hemi-/paraplegia, 1 due to recent hospitalization for pancreatitis and 1 due to a recent history of frequent flights. One of the 2 patients with a known previous PE had finished a course of anticoagulation when recurrent PE developed, and the other developed recurrent PE while on anticoagulation, despite inferior vena cava filter placement. Eight patients had documented DVT by CT or venous duplex scanning. Four patients (20%) required preoperative intubation secondary to PE. Twelve (60%) demonstrated preoperative intermittent hypotension treated with intravenous fluid boluses and vasopressors. Three patients suffered a cardiopulmonary arrest; this occurred preoperatively in 1 case and required cardiopulmonary resuscitation, and intraoperatively in 2 cases that then required emergency cardiopulmonary bypass. All patients undergoing echocardiography demonstrated signs of right ventricular failure, as described above. Indications for surgery included contraindication to thrombolysis due to recent surgery, clot in transit, or hemodynamic instability (table 3). Some patients had multiple contraindications to thrombolysis, and 1 had no strict contraindication but underwent surgery on clinical grounds. All patients underwent pulmonary embolectomy with cardiopulmonary bypass and 16 (80%) underwent cardioplegic arrest as described above. Three underwent patent foramen ovale closure and 8 underwent right atrial thrombectomy (right atrial clot was suspected in another patient, but no clot was found intraoperatively). Three additional patients had a patent foramen ovale with a clot straddling the defect into the left atrium, i.e. ‘paradoxical embolus in transit’. They underwent clot extraction via the right atrium and patent foramen ovale closure. In 1 of them, the left ventricle was explored via an aortotomy because the preoperative echocardiogram suggested that the left atrial component of the clot was crossing the mitral valve, but no left ventricular clot was found. Two patients underwent circulatory arrest as part of a caval tu108
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
mor thrombus extraction as described above. One patient presented with dyspnea as well as chest and left shoulder pain after a recent admission for pancreatitis. He was hypotensive and had a pulseless left upper extremity. He was found to have an atrial septal defect and CT scanning demonstrated PE with aortic arch thrombus involving the origin of the left subclavian artery. Pulmonary embolectomy, atrial septal defect closure and aortic arch and left subclavian artery thromboembolectomy were performed utilizing circulatory arrest. Two patients underwent coronary artery bypass grafting. One patient was a 65-year-old female with a history of DVT who developed massive PE several days after off-pump coronary artery bypass grafting for an anterior wall myocardial infarction. She developed severe right heart failure and despite inotropic support, intra-aortic balloon pump counterpulsation and additional bypass grafting, she could not be weaned from cardiopulmonary bypass and expired intraoperatively. The average cardiopulmonary bypass time was 62 min and average cross-clamp time was 34 min. The average time to extubation was 1.9 days. Postoperatively, most patients were placed on a continuous heparin infusion or Lovenox injections when considered safe from a surgical standpoint. Three patients had prior inferior vena cava filters in place, and all but 2 of the remaining patients underwent inferior vena cava filter placement during their hospitalization. All patients except for 1 were transitioned to either Coumadin or Lovenox injections prior to discharge. Two patients underwent reexploration on postoperative days 1 and 10 for suspected tamponade and 1 required reintubation for pneumonia. One patient required tracheostomy likely due to pneumonia and sepsis. All patients recovered well and were discharged in a satisfactory condition. The average postoperative length of hospital stay was 14.4 days. Survival to discharge and 30-day survival were both 95% and 1-year survival was 84%. Long-term follow-up was available in 95% of the patients, and long-term survival, at an average follow-up of 45 months (range 0–155), was 63%.
Discussion
In its more severe forms, PE can present with severe respiratory and hemodynamic instability, resulting in approximately 300,000 deaths annually in the USA [7]. Thrombolysis has been successfully employed in these settings, although a significant bleeding risk is incurred, including a 1–3% risk of intracranial hemorrhage. It is Worku/Gulkarov/Girardi/Salemi
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Table 3. Indications for surgery
show signs of right ventricular dysfunction on echocardiography or CT) have documented mortality rates of 6–8% [1, 4]. However, several other case series demonstrate much higher mortality rates, with the majority of deaths occurring in patients who require preoperative cardiopulmonary resuscitation [5, 13] as well as in those undergoing delayed pulmonary embolectomy [6] or prior failed thrombolysis [3]. In our series, all patients undergoing echocardiography had findings of right ventricular failure, indicating a high risk for subsequent deterioration. Fifteen percent had cardiopulmonary collapse and another 60% displayed intermittent hemodynamic instability. Despite this, we achieved a 95% survival rate. In the 25% who maintained hemodynamic stability throughout the preoperative period, survival was 100%. Several patients underwent aortic cross-clamping to improve the visibility. While it has been suggested that the increased risk of aortic cross-clamping in the setting of an already ischemic right ventricle is not warranted, we believe that, with adequate protection and short cross-clamp times, the risks are minimal and offset by the improved visualization obtained by a motionless heart [12]. Although exploration of the right pulmonary artery by a counter-incision between the superior vena cava and ascending aorta was only performed in 3 patients, we advocate the use of this approach without hesitation when necessary. Finally, 13 patients had a clot in transit, including 3 who had a right atrial clot traversing a patent foramen ovale into the left atrium, with distal arterial embolization imminent. In both scenarios, urgent surgical evacuation is recommended [1, 14]. The potential for recurrent PE and subsequent paradoxical embolus in the setting of a patent foramen ovale makes its closure another benefit of surgical treatment [14]. In conclusion, pulmonary embolectomy can be performed with excellent outcomes, even in the setting of preoperative hemodynamic instability or cardiac arrest. Right ventricular dysfunction in the hemodynamically stable patient is a strong predictor of impending hemodynamic compromise and should be considered an indication for intervention. While a contraindication to thrombolysis is an obvious indication for surgery, more studies are warranted to assess whether patients without such contraindications would be better served by surgery as well, when one considers the very low morbidity and mortality rates that we observed. We acknowledge several limitations to our study, including the small sample size and its retrospective nature. Larger, prospective, randomized studies are necessary to make more definitive conclusions.
Pulmonary Embolectomy
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
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therefore contraindicated in patients with intracranial, spinal or ocular disease, recent surgery or bleeding and during pregnancy [7]. Due to the high attendant mortality rates, pulmonary embolectomy has historically been reserved for patients with hemodynamic instability and shock who cannot tolerate the slower time course of clot resolution associated with thrombolysis and those with contraindications to thrombolysis. Mortality rates of 28–30% were reported in early studies of pulmonary embolectomy [4, 8–10], with rates as high as 64% in patients presenting with hemodynamic instability or cardiac arrest [8, 9]. The mortality rate for pulmonary embolectomy has declined in recent years, with some series reporting rates of
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism Berhane Worku a, b Iosif Gulkarov a, b Leonard N. Girardi a Arash Salemi a
a
Department of Cardiothoracic Surgery, Weill Cornell Medical College/New York Presbyterian Hospital, New York, N.Y., and b Department of Cardiothoracic Surgery, New York Methodist Hospital, Brooklyn, N.Y., USA
Abstract Objectives: Significant improvements in outcomes after pulmonary embolectomy have resulted in a broadening of indications. We reviewed our experience with pulmonary embolectomy over the past 12 years with an emphasis on preoperative comorbidities and postoperative morbidity and mortality. Methods: All patients undergoing pulmonary embolectomy over the past 12 years at our institution were analyzed via retrospective chart review. Data on preoperative characteristics, operative procedures and postoperative outcomes were collected. Results: Twenty patients underwent pulmonary embolectomy between 1999 and 2011. The average age was 56 years (range 24–81) and 10 patients (50%) were female. All patients demonstrated right ventricular dysfunction and 19 (95%) demonstrated contraindications to thrombolysis. Twelve patients (60%) demonstrated intermittent hypotension, 4 (20%) required intubation and 3 (15%) demonstrated preoperative or intraoperative cardiac arrest. Survival to discharge was 95%. Conclusions: Pulmonary embolectomy has been shown to be safe and effective in the treatment of massive pulmonary embolism (PE). We achieved a 95% survival rate in a cohort of patients with sig-
© 2014 S. Karger AG, Basel 0008–6312/14/1292–0106$39.50/0 E-Mail [email protected] www.karger.com/crd
nificant comorbid status. Pulmonary embolectomy should be considered early in the therapeutic algorithm for patients with submassive PE presenting with right ventricular dysfunction to prevent progression. It can also be performed with good outcomes in those already suffering hemodynamic compromise. © 2014 S. Karger AG, Basel
Introduction
Pulmonary embolism (PE) can present with a wide range of severity. Milder forms may be asymptomatic and are adequately treated with anticoagulation alone. Acute massive PE presenting with respiratory and hemodynamic collapse and shock is a highly lethal event requiring more aggressive treatment, usually including surgical pulmonary embolectomy. The treatment of submassive PE presenting with stable hemodynamics in the setting of right ventricular strain on echocardiography [1, 2] or computed tomography (CT) scanning [3] has been more controversial. Strategies include thrombolysis, catheter embolectomy and surgical pulmonary embolectomy. In recent years as the outcomes for surgical embolectomy have improved, the range of indications has broadened, and some groups now consider it the treatment of choice for submassive PE [1, 4–6]. We reviewed our experience Berhane Worku 525 East 68th St M525 New York, NY 10021 (USA) E-Mail bmworku @ hotmail.com
Downloaded by: Imperial College, School of Medicine, Wellcome Libr. 155.198.30.43 - 2/19/2015 10:15:08 AM
Key Words Pulmonary embolism · Embolectomy · Deep vein thrombosis
Materials and Methods A retrospective review of hospital records of all patients who underwent pulmonary embolectomy at our institution over the past 12 years was performed. Data collected included demographic variables, presenting characteristics, risk factors, diagnostic imaging modalities, hemodynamic and respiratory status, operative procedures, operative times, postoperative complications and anticoagulation protocols. This study was conducted in accordance with the amended Declaration of Helsinki. From June 1999 to October 2011, 20 patients underwent pulmonary embolectomy at our institution. The average age was 56 years (range 24–81) and 10 patients (50%) were female. All patients underwent CT scanning for the diagnosis of PE, and 17 (85%) underwent transthoracic or transesophageal echocardiogram for the assessment of ventricular function. Right ventricular dysfunction was considered present in the setting of right ventricular dilation, decreased contractility or tricuspid regurgitation. The presence of deep vein thrombosis (DVT) was assessed by CT scanning and/or venous duplex scanning. Surgical Technique Median sternotomy was performed in all cases. Arterial cannulation was performed via the ascending aorta, and venous cannulation was performed via a single cannula in the right atrium or via bicaval cannulation, depending on the need for right atrial exploration (e.g. a clot in transit or patent foramen ovale). All cases were performed on full cardiopulmonary bypass with mild hypothermia. Aortic cross-clamping with cold potassium cardioplegia arrest and circulatory arrest were utilized at the surgeon’s discretion and based on the need for associated procedures. The main pulmonary artery was incised and all clots were extracted with forceps, Fogarty catheters and flushing. In 3 patients, the right pulmonary artery was explored separately via an incision between the aorta and the superior vena cava to extract more distal clot. Patients were weaned from cardiopulmonary bypass with the use of inotropes, vasopressors and intra-aortic balloon pump assistance as necessary.
Results
From June 1999 to October 2011, 20 patients underwent pulmonary embolectomy at our institution, with 9 (45%) having been transferred from an outside institution. Symptoms and signs included dyspnea, with 4 patients requiring intubation, chest pain, altered mental status, syncope, tachycardia, and hypotension, with 3 patients suffering cardiac arrest. Two patients with known caval and right atrial tumor thrombus, due to chrondroma and renal cell carcinoma, respectively, underwent Pulmonary Embolectomy
Table 1. Demographics and presenting characteristics
n (%)1 Age, years Female Transfer from outside hospital Symptoms/signs Dyspnea Intubation Altered mental status Syncope Chest pain Tachycardia Hypotension Cardiac arrest 1
56 (24 – 81) 10 (50) 9 (45) 16 (80) 4 (20) 1 (5) 4 (20) 4 (20) 13 (65) 12 (60) 3 (15)
Unless otherwise indicated.
Table 2. Risk factors for development of PE
n (%) Recent surgery Orthopedic Neurosurgical Vascular Cardiac Thoracic Gynecological Neoplasia Immobility Previous PE
11 (55) 6 (30) 1 (5) 1 (5) 1 (5) 1 (5) 1 (5) 7 (35) 9 (45) 2 (10)
elective surgery for tumor thrombus extraction under circulatory arrest. One of them developed a large PE intraoperatively, which required emergency cardiopulmonary bypass. One patient had suffered multisystem trauma in another country several days before, which had resulted in paraplegia. She was transferred to our institution, where, after stabilization of her orthopedic injuries, she underwent prophylactic inferior vena cava filter placement. Massive PE occurred during the procedure and an emergency pulmonary embolectomy was performed. Demographics and presenting characteristics are outlined in table 1. Risk factors for the development of PE included recent surgery, active cancer, immobility and previous DVT/PE (table 2). Surgical procedures occurred within an average of 17.3 days prior to the development of PE. Five patients had a history of immobility secondary to recent orthopeCardiology 2014;129:106–110 DOI: 10.1159/000363647
107
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with pulmonary embolectomy over the past 12 years, with an emphasis on presenting characteristics, indications for surgery, operative findings and outcomes.
n (%) Recent surgery (thrombolysis contraindicated) Clot in transit Right atrial clot suspected Paradoxical clot in transit Aortic thrombus Hemodynamic instability/preoperative arrest
9 (45) 13 (65) 9 (45) 3 (15) 1 (5) 13 (65)
dic procedures, 2 due to a history of hemi-/paraplegia, 1 due to recent hospitalization for pancreatitis and 1 due to a recent history of frequent flights. One of the 2 patients with a known previous PE had finished a course of anticoagulation when recurrent PE developed, and the other developed recurrent PE while on anticoagulation, despite inferior vena cava filter placement. Eight patients had documented DVT by CT or venous duplex scanning. Four patients (20%) required preoperative intubation secondary to PE. Twelve (60%) demonstrated preoperative intermittent hypotension treated with intravenous fluid boluses and vasopressors. Three patients suffered a cardiopulmonary arrest; this occurred preoperatively in 1 case and required cardiopulmonary resuscitation, and intraoperatively in 2 cases that then required emergency cardiopulmonary bypass. All patients undergoing echocardiography demonstrated signs of right ventricular failure, as described above. Indications for surgery included contraindication to thrombolysis due to recent surgery, clot in transit, or hemodynamic instability (table 3). Some patients had multiple contraindications to thrombolysis, and 1 had no strict contraindication but underwent surgery on clinical grounds. All patients underwent pulmonary embolectomy with cardiopulmonary bypass and 16 (80%) underwent cardioplegic arrest as described above. Three underwent patent foramen ovale closure and 8 underwent right atrial thrombectomy (right atrial clot was suspected in another patient, but no clot was found intraoperatively). Three additional patients had a patent foramen ovale with a clot straddling the defect into the left atrium, i.e. ‘paradoxical embolus in transit’. They underwent clot extraction via the right atrium and patent foramen ovale closure. In 1 of them, the left ventricle was explored via an aortotomy because the preoperative echocardiogram suggested that the left atrial component of the clot was crossing the mitral valve, but no left ventricular clot was found. Two patients underwent circulatory arrest as part of a caval tu108
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
mor thrombus extraction as described above. One patient presented with dyspnea as well as chest and left shoulder pain after a recent admission for pancreatitis. He was hypotensive and had a pulseless left upper extremity. He was found to have an atrial septal defect and CT scanning demonstrated PE with aortic arch thrombus involving the origin of the left subclavian artery. Pulmonary embolectomy, atrial septal defect closure and aortic arch and left subclavian artery thromboembolectomy were performed utilizing circulatory arrest. Two patients underwent coronary artery bypass grafting. One patient was a 65-year-old female with a history of DVT who developed massive PE several days after off-pump coronary artery bypass grafting for an anterior wall myocardial infarction. She developed severe right heart failure and despite inotropic support, intra-aortic balloon pump counterpulsation and additional bypass grafting, she could not be weaned from cardiopulmonary bypass and expired intraoperatively. The average cardiopulmonary bypass time was 62 min and average cross-clamp time was 34 min. The average time to extubation was 1.9 days. Postoperatively, most patients were placed on a continuous heparin infusion or Lovenox injections when considered safe from a surgical standpoint. Three patients had prior inferior vena cava filters in place, and all but 2 of the remaining patients underwent inferior vena cava filter placement during their hospitalization. All patients except for 1 were transitioned to either Coumadin or Lovenox injections prior to discharge. Two patients underwent reexploration on postoperative days 1 and 10 for suspected tamponade and 1 required reintubation for pneumonia. One patient required tracheostomy likely due to pneumonia and sepsis. All patients recovered well and were discharged in a satisfactory condition. The average postoperative length of hospital stay was 14.4 days. Survival to discharge and 30-day survival were both 95% and 1-year survival was 84%. Long-term follow-up was available in 95% of the patients, and long-term survival, at an average follow-up of 45 months (range 0–155), was 63%.
Discussion
In its more severe forms, PE can present with severe respiratory and hemodynamic instability, resulting in approximately 300,000 deaths annually in the USA [7]. Thrombolysis has been successfully employed in these settings, although a significant bleeding risk is incurred, including a 1–3% risk of intracranial hemorrhage. It is Worku/Gulkarov/Girardi/Salemi
Downloaded by: Imperial College, School of Medicine, Wellcome Libr. 155.198.30.43 - 2/19/2015 10:15:08 AM
Table 3. Indications for surgery
show signs of right ventricular dysfunction on echocardiography or CT) have documented mortality rates of 6–8% [1, 4]. However, several other case series demonstrate much higher mortality rates, with the majority of deaths occurring in patients who require preoperative cardiopulmonary resuscitation [5, 13] as well as in those undergoing delayed pulmonary embolectomy [6] or prior failed thrombolysis [3]. In our series, all patients undergoing echocardiography had findings of right ventricular failure, indicating a high risk for subsequent deterioration. Fifteen percent had cardiopulmonary collapse and another 60% displayed intermittent hemodynamic instability. Despite this, we achieved a 95% survival rate. In the 25% who maintained hemodynamic stability throughout the preoperative period, survival was 100%. Several patients underwent aortic cross-clamping to improve the visibility. While it has been suggested that the increased risk of aortic cross-clamping in the setting of an already ischemic right ventricle is not warranted, we believe that, with adequate protection and short cross-clamp times, the risks are minimal and offset by the improved visualization obtained by a motionless heart [12]. Although exploration of the right pulmonary artery by a counter-incision between the superior vena cava and ascending aorta was only performed in 3 patients, we advocate the use of this approach without hesitation when necessary. Finally, 13 patients had a clot in transit, including 3 who had a right atrial clot traversing a patent foramen ovale into the left atrium, with distal arterial embolization imminent. In both scenarios, urgent surgical evacuation is recommended [1, 14]. The potential for recurrent PE and subsequent paradoxical embolus in the setting of a patent foramen ovale makes its closure another benefit of surgical treatment [14]. In conclusion, pulmonary embolectomy can be performed with excellent outcomes, even in the setting of preoperative hemodynamic instability or cardiac arrest. Right ventricular dysfunction in the hemodynamically stable patient is a strong predictor of impending hemodynamic compromise and should be considered an indication for intervention. While a contraindication to thrombolysis is an obvious indication for surgery, more studies are warranted to assess whether patients without such contraindications would be better served by surgery as well, when one considers the very low morbidity and mortality rates that we observed. We acknowledge several limitations to our study, including the small sample size and its retrospective nature. Larger, prospective, randomized studies are necessary to make more definitive conclusions.
Pulmonary Embolectomy
Cardiology 2014;129:106–110 DOI: 10.1159/000363647
109
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therefore contraindicated in patients with intracranial, spinal or ocular disease, recent surgery or bleeding and during pregnancy [7]. Due to the high attendant mortality rates, pulmonary embolectomy has historically been reserved for patients with hemodynamic instability and shock who cannot tolerate the slower time course of clot resolution associated with thrombolysis and those with contraindications to thrombolysis. Mortality rates of 28–30% were reported in early studies of pulmonary embolectomy [4, 8–10], with rates as high as 64% in patients presenting with hemodynamic instability or cardiac arrest [8, 9]. The mortality rate for pulmonary embolectomy has declined in recent years, with some series reporting rates of
