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Ann Thorac Surg 2004;77:819-823
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Open pulmonary embolectomy for treatment of major pulmonary embolism

^a Department of Surgery, Division of Cardiothoracic Surgery, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
^b Pulmonary and Critical Care Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA
^c Internal Medicine, Westchester Medical Center/New York Medical College, Valhalla, New York, USA

Accepted for publication August 15, 2003.

^* Address reprint requests to Dr Fleisher, Cardiothoracic Surgery, Westchester Medical Center, Macy Pavilion, Valhalla, NY 10595, USA
e-mail: fleishera{at}wcmc.com

	Abstract

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BACKGROUND: Inadequate data exist regarding the management of acute major pulmonary embolism. Various modalities that are used, including thrombolytics and embolectomy, have not been shown to conclusively improve mortality when compared to heparin. In the past, open pulmonary embolectomy was reserved for patients with severe hemodynamic instability because of its high mortality rate. Our objective was to analyze our experience with early embolectomy as an alternative for the treatment of major pulmonary embolism.

METHODS: A retrospective review of charts of all patients undergoing pulmonary embolectomy at our institution over the last two years was performed. Patients were followed until their discharge from hospital.

RESULTS: There were 13 patients (7 women and 6 men). Four had massive and 9 had submassive pulmonary embolism. There was one mortality. Postoperative echocardiography showed no evidence of pulmonary hypertension in 7.

CONCLUSIONS: Open pulmonary embolectomy can be performed in patients with major pulmonary embolism with minimal mortality and morbidity. It may prevent the development of chronic thromboembolic pulmonary hypertension and should be a part of the algorithm in the treatment of major pulmonary embolism.

	Introduction

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Acute major pulmonary embolism (which includes massive and submassive pulmonary embolism) has a high mortality rate despite advances in diagnosis and treatment [1]. For clinical purposes, massive pulmonary embolism is defined as pulmonary embolism with shock and submassive pulmonary embolism as hemodynamically stable pulmonary embolism with right ventricular dysfunction [2]. Optimal management remains controversial despite the availability of several different modalities of treatment including anticoagulation with heparin, thrombolysis, catheter embolectomy, and open pulmonary embolectomy. In the past, open pulmonary embolectomy was reserved for patients with massive pulmonary embolism and severe hemodynamic instability. The purpose of this study was to analyze our experience over the past two years with early open pulmonary embolectomy as a modality of treatment for patients with a major pulmonary embolus.

	Material and methods

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A retrospective review of hospital records of all patients who underwent pulmonary embolectomy at our hospital over the past two years was performed. The hospital charts were reviewed for symptoms on presentation, mode of diagnosis, hemodynamic status, preoperative and intraoperative echocardiograms, operative procedure, cardiopulmonary bypass and cross clamp times, postoperative time to extubation, morbidity, and mortality.

Patient population
There were 826 helical computed tomographic scans performed over a period of 2 years in patients with signs and symptoms suggestive of acute pulmonary embolism such as sudden onset dyspnea, pleuritic chest pain, hypotension, syncope, tachypnea, tachycardia, and hypoxia. Of these, 165 (19%) were positive for pulmonary embolus. From September 2000 to March 2002, 13 patients (6 male and 7 female) with average age of 54 (range, 35 to 73) (Table 1), diagnosed with massive or submassive pulmonary embolism, were treated by open pulmonary embolectomy. Five patients were diagnosed in our hospital while the others were referred from other hospitals for further management after the diagnosis was made. Four of them had massive pulmonary embolism and 9 had submassive pulmonary embolism. Six (46%) patients required intubation before the surgery. The indication for surgery was acute hemodynamic or respiratory compromise with a major pulmonary embolus. The diagnosis of pulmonary embolism was made by helical computed tomographic scan in 10 (Fig 1), at operation by transesophageal echocardiogram (TEE) in 2 patients, and by pulmonary angiography in 1 patient. Two patients suffered cardiac arrest preoperatively requiring cardiopulmonary resuscitation. Pulmonary embolus was diagnosed in these two patients by intraoperative TEE. Four patients were hypotensive and required pressors. All patients had dilated hypokinetic right ventricles at the time of surgery, confirming the diagnosis of massive(submassive) pulmonary embolism.

View larger version (188K): [in this window] [in a new window]   Fig 1. Spiral computed tomography showing a saddle pulmonary embolus (arrow).

	Results

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Twelve (92%) patients survived the open pulmonary embolectomy and were discharged from the hospital. The two patients who presented with cardiopulmonary arrest before the pulmonary embolectomy suffered hypoxemic encephalopathy. They were in the operating room for other procedures when they became hemodynamically unstable and had an intraoperative TEE, confirming the diagnosis of pulmonary embolism. The first patient was undergoing a liver transplant and although the patient recovered hemodynamically postembolectomy, the patient did not regain consciousness and care was withdrawn as per the family's wishes. This was the only mortality in our study. The second patient was undergoing spine surgery when the diagnosis of pulmonary embolism was made. This patient was discharged to a nursing home. A third patient, who was septic, had myocardial infarction; cerebral embolus preoperatively required prolonged ventilatory support postoperatively. Echocardiography did not reveal any atrial septal defect or mural thrombus in this patient. This was the only surgically related morbidity.

Ten (77%) patients were extubated on postoperative day 1; postoperative echocardiogram was performed on 9 of these patients before discharge. There was no echocardiographic evidence of pulmonary hypertension in 7. One had moderate to severe and another moderate pulmonary hypertension.

	Comment

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Prevalence of pulmonary embolism in hospitalized patients is around 1% [3, 4]. In spite of the current emphasis on deep venous thrombus (DVT) prophylaxis, there is a failure rate of about 30% to 50% [5]. Spiral computed tomography is performed in our hospital as the diagnostic modality of choice for the diagnosis of pulmonary embolism because of the nonspecific nature of symptoms in patients with pulmonary embolism, the noninvasive nature of the procedure, and it's easy availability and safety [6–8]. While it can be argued that performing a pulmonary angiogram when pulmonary embolism is the leading diagnosis can also be therapeutic, most of the currently available percutaneous catheters do not remove the clot but rather fragment it into small particles [9].

It is widely accepted that thrombolysis(embolectomy) is the treatment of choice for patients with massive pulmonary embolism even though their effect on improvement of mortality has not been conclusively proven. The treatment of submassive pulmonary embolism is, however, controversial though there has been a recent trend towards the use of thrombolytics in this group [10–12].

Right ventricular (RV) dysfunction is seen in 30% to 40% of patients with hemodynamically stable pulmonary embolism [13]. When compared with patients without RV dysfunction, these patients have an increased risk of pulmonary embolism related shock (10%) and in hospital mortality (5%) [13, 14]. A recent randomized prospective study of heparin versus heparin and alteplase for the treatment of submassive pulmonary embolism did not reveal any survival benefit to the use of thrombolytics in this subgroup of patients, even though the patients treated with thrombolytics initially required fewer interventions during the course of their hospital stay [15].

It has been found that patients with acute pulmonary embolism, who have severe pulmonary hypertension (pulmonary artery [PA] systolic pressures > 50) at the time of diagnosis, had a higher chance of developing chronic thromboembolic pulmonary hypertension requiring pulmonary thromboendarterectomy [16]. It is estimated that 0.1% to 0.5% of people with acute pulmonary embolism who survive develop chronic thromboembolic pulmonary hypertension [17]. The persistence of pulmonary hypertension postembolization has been recognized as an independent predictor of mortality [18, 19]. When compared to open pulmonary embolectomy, pulmonary thromboendarterectomy is more complicated, done in fewer centers, and has an associated mortality of 10% to 25% [18].

In the past, pulmonary embolectomy was the treatment of last resort for patients with pulmonary embolism due to its associated high mortality rate (30%) (Table 2). We were able to perform open pulmonary embolectomy in all our patients without major complications. All cases were performed using cardiopulmonary bypass and vacuum assisted venous drainage. Use of femoral-femoral bypass, which can be used as an alternative to standard cannulation in unstable patients, was not required in our patients [20]. We did not systematically explore the inferior vena cava, right atrium, or the right ventricle during the surgery but relied on the results of noninvasive studies for the location of the clots. If the clot is only present in the pulmonary artery, then a two-stage single venous cannula can be used. Other strategies for venous cannulation may be necessary if additional clots are present in any of the other locations. These can include bicaval cannulation, cannulation of the superior vena cava, right atrium, or the femoral vein. Routine intraoperative transesophageal echocardiography can be used to diagnose right atrial pathology and evaluate the effectiveness of the procedure. Intraoperative fiber-optic angioscopy has also been used by some surgeons to evaluate the completeness of clot removal [21].

The difference in surgical technique in our series is explained by the fact that 5 surgeons with different surgical preferences were performing the procedure. However, we believe that there is no advantage of hypothermia and cross clamping and that this procedure can be performed at normothermia without cross clamping the aorta [22].

Certain patients in this study could have been candidates for heparin and thrombolytics. In one of the few studies that compared medical versus surgical treatment of massive pulmonary embolism, medically treated patients had a higher death rate (33% vs 23%), increased risk of major hemorrhage (25%), and increased recurrence rate of pulmonary embolism [23]. Catheter embolectomy has a success rate of approximately 80%, but there is a danger of distal dispersion of a proximal pulmonary embolus [24, 25].

While open pulmonary embolectomy requires the resources of cardiac surgery centers, it seems to be a safe and effective alternative to thrombolysis or catheter thrombectomy in the treatment of major pulmonary embolism. Aggressive initial treatment of submassive pulmonary embolism may improve the in-hospital clinical course of these patients and may prevent the development of chronic thromboembolic pulmonary hypertension. An additional advantage of open embolectomy is that around 50% of patients who are candidates for thrombolysis have some contraindication that precludes the use of thrombolytics [26].

We believe that to improve outcomes (short term and long term) of pulmonary embolism, early decision making on surgical intervention is essential since all modalities of treatment have varying degrees of failure and risks. Patients with helical computerized axial tomographic (CAT) scan, showing submassive pulmonary embolus, should have an evaluation of the right ventricle with an echocardiogram. Patients with RV dysfunction on the echocardiogram should be considered for early open pulmonary embolectomy. Although a randomized prospective study comparing the three modalities of treatment could resolve the issue, it is unlikely that it will be performed in the near future or at all because of logistical and ethical reasons. In the absence of this evidence we would recommend early open pulmonary embolectomy as part of the treatment algorithm for patients with massive and submassive pulmonary embolus.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Arlen G. Fleisher Howard I. Axelrod Mohan R. Sarabu Elias A. Zias Richard A. Moggio Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Yalamanchili, K. Articles by Moggio, R. A. Search for Related Content PubMed PubMed Citation Articles by Yalamanchili, K. Articles by Moggio, R. A. Related Collections Great vessels