Ann Thorac Surg 2000;69:1248-1249
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Pulmonary embolectomy in a child
Dumbor L. Ngaage, FRCSa,
Ishtiaq Ahmed, MB, ChBa,
Venkatachalam Chandrasekaran, FRCSa
a Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds, United Kingdom
Address reprint requests to Dr Chandrasekaran, Department of Cardiothoracic Surgery, Yorkshire Heart Centre, Leeds General Infirmary, Leeds LS1 3EX, UK
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Abstract
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We report the case of a 14-year-old boy treated successfully by pulmonary embolectomy for massive pulmonary embolism, 18 days after bilateral hip surgery. He has a family history of pulmonary embolism and an inherited antithrombin deficiency. His diagnosis was confirmed by spiral computed tomography scan. We believe that pulmonary embolectomy has a role in selected cases in children.
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Introduction
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Acute massive pulmonary embolism is a potentially lethal clinical condition infrequently diagnosed in children. Prompt diagnosis and institution of appropriate treatment is clearly the way to reduce the associated high mortality. Anticoagulation alone or in combination with thrombolytic therapy is usually the first line of treatment [1–3]. Concern has been expressed about both forms of treatment in children [3, 4]. Pulmonary embolectomy is rarely carried out as a primary treatment procedure in children, and as such, there are not many reports in the literature about embolectomy in children. We report the case of a 14-year-old boy with massive pulmonary embolism treated successfully by pulmonary embolectomy, because of its rarity. We believe that pulmonary embolectomy can be used selectively as treatment for massive pulmonary embolism in children with good result.
A 14-year-old obese boy was transferred to our unit from the Accident and Emergency department of a district hospital with a history of brief loss of consciousness, acute onset chest pain, and tachypnea. Eighteen days before presentation, he underwent fixation of bilateral slipped upper femoral epiphysis.
His 38-year-old mother has had three episodes of pulmonary embolism: while on oral contraceptives, during pregnancy, and after a minor surgical procedure.
He was in sinus tachycardia at 138 per minute, with a blood pressure of 112/64 mm Hg, and jugular venous pressure of 3 cm. He had a respiratory rate of 32 per minute, oxygen saturation of 90%, pO2 8.5 kPa, pCO2 4.1 kPa, and a pH of 7.48 on 80% of oxygen by face mask. His electrocardiogram and transthoracic echocardiogram showed evidence of right heart strain. A spiral computed tomography scan showed a massive saddle embolus in the pulmonary trunk extending into the right and left pulmonary arteries and almost occluding them (Fig 1). A sonovenogram showed no thrombus in the femoral and iliac veins, and inferior vena cava. During his hospital stay, the anti-thrombin III activity in both his mother and himself was found to be only 60% of normal. Although the patient was not severely compromised hemodynamically, he was dyspneic and oxygen dependent. We decided to perform a pulmonary embolectomy, in view of the large embolus in the pulmonary arteries, and he was taken to the operating theater 6 hours after admission.
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Fig 1. Spiral computed tomography scan of the chest showing a massive embolus almost occluding the pulmonary arterial system.
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Using a standard median sternotomy and cardiopulmonary bypass, with fibrillatory arrest of the heart, the embolus was successfully removed through a vertical pulmonary arteriotomy. The embolus (Fig 2) extended 9 cm into the right and 11 cm into the left pulmonary arteries. There was a 3-cm extension into the right upper lobe artery, and the caliber varied from 12 to 5 mm. He was anticoagulated postoperatively with heparin and warfarin. The patient recovered uneventfully and was discharged on the 6th postoperative day. The histology of the embolus showed it to be platelet and fibrin rich with small amounts of red cell entrapment, but the majority consisted of consecutive propagated thrombus. He was reviewed at the follow-up clinic 2 months after discharge and he is doing well. He was advised to continue warfarin and referred to the hematologist.
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Fig 2. Embolus recovered from the pulmonary arterial system at operation in its pathological distribution. To the left is the extension of the embolus into the left pulmonary arterial system, and so for the right. The measuring rule below the specimen shows the length of the embolus.
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Comment
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There is little in the literature about acute pulmonary embolectomy in children. Since the first successful pulmonary embolectomy using cardiopulmonary bypass by Sharp in 1962, this procedure is used mainly in two categories of patients with pulmonary embolism, namely: those who remain hemodynamically unstable more than 1 hour after the acute event [2], and those whose clinical condition deteriorates on medical therapy [3]. Goldsby and associates reported the case of a 13-year-old who had pulmonary embolectomy because she deteriorated clinically on anticoagulation and thrombolytic therapy [3]. It therefore follows that the very ill patients are selected for surgery, which explains the high mortality associated with acute pulmonary embolectomy [2]. We carried out pulmonary embolectomy as a first line of treatment in this patient because we were concerned about the massive size of the embolus, as well as the near total occlusion of the main pulmonary arteries. This ensured that he was operated on before he became very ill, and provided a definitive means of removing the large pulmonary embolus. This treatment was associated with a very low morbidity in the patient and he was fit for early discharge.
Pulmonary embolectomy can be used successfully, with low morbidity and mortality, in selected cases, in children with massive pulmonary embolism.
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References
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Evans D.A., Wilmott R.W. Pulmonary embolism in children. Pediatr Clin North Am 1994;41:569-584.[Medline]
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Goldsby R.E., Saulys A.J., Helton J.G. Pediatric pulmonary artery thromboembolism. Pediatr Emerg Care 1996;12:105-107.[Medline]
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Palla A., Giuntini C. Highlights and final remarks. Chest 1995;107(Suppl):56-57.
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Melanson S.W., Silver B., Heller M.B. Deep vein thrombosis, pulmonary embolism, and the white clot syndrome. Am J Emerg Med 1996;14:558-560.[Medline]
Accepted for publication July 31, 1999.
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Abstract
Introduction
