Ann Thorac Surg 2008;85:1471-1472. doi:10.1016/j.athoracsur.2007.09.005
© 2008 The Society of Thoracic Surgeons
How To Do It
Retrograde Pulmonary Embolectomy in 11 Patients
Khalil Zarrabi, MDa,
Reza Mollazadeh, MDb,*,
Mohammad Ali Ostovan, MDb,
Ali Reza Abdi Ardekani, MDb
a Department of Cardiac Surgery, Nemazee Hospital, Shiraz University of Medical Science, Shiraz, Iran
b Department of Cardiology, Nemazee Hospital, Shiraz University of Medical Science, Shiraz, Iran
Accepted for publication September 5, 2007.
* Address correspondence to Dr Mollazadeh, Department of Cardiology, Nemazee Hospital, Zand Avenue, Shiraz, Fa, 71435-1414, Iran (Email: mollazar{at}yahoo.com).
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Abstract
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Eleven consecutive patients who had received diagnosis of massive and submassive pulmonary emboli underwent operations. After performing conventional pulmonary embolectomy, we tried to evacuate the impacted thrombus from the minor branches with the retrograde pulmonary vein perfusion. The combined amount of the removed clot was much more than that removed with the antegrade technique (p = 0.001). Postoperative echocardiography showed a significant decrease in systolic pulmonary artery pressure and right to left ventricle dimensions (p = 0.008 and 0.007, respectively). Although the results should not be excessively interpreted, this technique seems to be effective in removing the distal thrombi.
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Introduction
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Despite advances in diagnosis and therapeutic techniques, acute pulmonary emboli (PE) are still associated with a high mortality rate. Treatment options used in massive PE include thrombolysis, catheter embolectomy, and surgical embolectomy. Conventional pulmonary embolectomy fails to optimally evacuate the peripheral pulmonary beds from thrombus and thus impedes recovery to preoperation pulmonary artery pressure (PAP) [1, 2]. Satisfactory results in the first patient [3] led us to believe that this technique can be applied to other qualified patients.
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Technique
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The study data was derived from a quadri-center prospective Shiraz Pulmonary Emboli Registry of 106 consecutive patients with PE admitted to our four collegiate hospitals between January 2004 and November 2006. The patients were operated on if they had received diagnosis of massive or submassive PE and (1) had contraindication(s) to thrombolytic treatment or (2) lacked any response to thrombolysis, or both.
After performing conventional embolectomy, the interatrial septum was opened through an incision made on the area corresponding to fossa ovalis. The pulmonary vein orifices in the left atrium were identified and an endotracheal tube of size 5-French to 5.5-French (with its cuff inflated) was inserted to it. The oxygenated blood was infused from the pump for 60 to 80 seconds to each pulmonary vein. The pulmonary veins became full of blood in a retrograde fashion, and blood and small thrombi fragments began to appear in the pulmonary artery and were washed out. The thrombi evacuated before and after initiation of the retrograde technique were weighed. The atrial septal defect was closed. Pulmonary artery pressure before starting and after termination of cardiopulmonary bypass was recorded. The patients were primarily kept anti-coagulated with intravenous unfractionated heparin and then with warfarin.
The endpoints of this study were combined clinically and echocardiographically (systolic PAP, right to left ventricle dimension ratio) follow-up of patients for a period of six months during outpatient visits. The ethics committee approved this study.
Eleven patients (4 men and 7 women) were included in the study. Their mean age was 58.27 ± 11.24 (range, 32 to 75 years). Mean blood pressure was 84.36 ± 13.09 (mm Hg) (4 patients received inotrops before operation). Nine patients were in functional class IV (with cardiopulmonary resuscitation in 3 patients). Pulmonary emboli were initially diagnosed by spiral computed tomographic scans in 9 and transesophageal echocardiography in 2 patients, respectively. The clots were removed with a conventional or complementary method and were 0.77 ± 0.13 gram and 1.15 ± 0.37 gram, respectively (p value = 0.005) (Fig 1). The combined amount of clot removed was significantly greater than that removed with the antegrade technique (p value = 0.001). Mean PAP at the beginning and after termination of the operation was 46.45 ± 11 mm Hg versus 29.72 ± 10.11 mm Hg, respectively (p value = 0.003). Two patients had persistent, severe right ventricle dysfunction and expired immediately postoperatively. The 6-month follow-up was completed for the remaining patients. All the follow-up echocardiographic data are presented in Table 1. Functional class of the patients at the end of 6 months was as follows: 4 patients in class I, 3 in class II, 1 in class III, and 1 in class IV. The last patient had pulmonary silicosis and was in class III before the occurrence of PE.
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Fig 1. (A) Large thrombi that were evacuated with conventional method. (B) Smaller clots dislodged during retrograde technique.
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Comment
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We believe there has been no previous study reported that has ever assessed the effect of retrograde pulmonary embolectomy (with the technique described) in the treatment of PE. We believe that our study is the first to report the immediate and intermediate clinical and echocardiographic findings of the patients who have undergone this or similar procedures.
The overall in-hospital mortality (2 in 11 patients [18.18%]) in this study somehow accords with that of previously published results using a conventional technique [1]. The terms "cancer" and "heart failure" were addressed as the major causes of death after 1 month [4]. Considering that none of our patients were affected by cancer and just 1 patient had heart failure, the absence of late mortality in our study would probably be justifiable.
To date, the amount of the extracted clot has never been measured. Much more clot was evacuated from distal branches with the retrograde technique than with the conventional method (p = 0.005), and the combined amount of clot removed was much more than that removed with the antegrade technique (p = 0.001).
Ribeiro and colleagues [5] showed that in patients with acute PE and increased PAP, the pattern of the change in PAP in 1 year was characterized by an initial dynamic phase followed by a stable phase, which was achieved within 30 days in 90% of patients. Despite differences in materials and methods between this study and that of the mentioned studies, the results are in the same line concerning the decrease in PAP and right to left ventricle dimension between preoperative echocardiography versus 1-month and 6-month echocardiographic data, but there was no significant decrease between 1-month and 6-month echocardiographic findings.
Janke [6] performed retrograde pulmonary embolectomy for the first time, but without the use of cardiopulmonary bypass. After many years of disuse, retrograde pulmonary perfusion has been successfully used as an aid to treat acute PE in a few isolated cases recently. The largest study was retrospectively conducted by Spagnolo and colleagues [7] with retrograde pulmonary perfusion through the left atrium and right upper pulmonary vein. They pointed out that: "It helps to flush out residual thrombotic material lodged in the distal pulmonary branches." But we believe that our technique is more efficacious for removing impacted thrombus in distal branches because: (1) filling the left atrium by the retrograde pulmonary perfusion technique will not raise pulmonary vein pressure enough to dislodge impacted thrombus; (2) by retrograde perfusion of each pulmonary vein one by one, all the force is delivered to one pulmonary vein; therefore, much more clot is evacuated; (3) pulmonary vein exposure when approached through the patent foramen ovale is much better than the left atrium roof incision. Noteworthy, our study was conducted prospectively, but their study was performed retrospectively.
In conclusion, although our method should not be over-interpreted because the study only included 11 cases, it is simple and effective in removing small fragments of thrombi dislodged in the peripheral segments. There is a need to review this technique in larger experimental studies before it can be safely used as a new technique.
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References
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- Stein PD, Alnas M, Beemath A, Patel NR. Outcome of pulmonary embolectomy Am J Cardiol 2007;99:421-423.[Medline]
- Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism Ann Thorac Surg 2005;79:1240-1244.[Abstract/Free Full Text]
- Zarrabi K, Yarmohammadi H, Ostovan MA. Retrograde pulmonary embolectomy in massive pulmonary embolism Eur J Cardiothorac Surg 2005;28:897-899.[Abstract/Free Full Text]
- Leacche M, Unic D, Goldhaber SZ, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach J Thorac Cardiovasc Surg 2005;129:1018-1023.[Abstract/Free Full Text]
- Ribeiro A, Lindmaker P, Johnsson H, et al. Pulmonary embolism: one-year follow-up with echocardiography Doppler and five-year survival analysis Circulation 1999;99:1325-1330.[Abstract/Free Full Text]
- Janke WH. Pulmonary embolectomy: retrograde approach without use of a heart-lung bypass JAMA 1968;206:127-128.[Abstract/Free Full Text]
- Spagnolo S, Grasso MA, Tesler UF. Retrograde pulmonary perfusion improves results in pulmonary embolectomy for massive pulmonary embolism Tex Heart Inst J 2006;33:473-476.[Medline]
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Abstract
Introduction
