Original article
Adult cardiac
Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients

Presented at the Sixty-first Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 5–8, 2014.
https://doi.org/10.1016/j.athoracsur.2015.03.111Get rights and content

Background

Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period.

Methods

Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients.

Results

Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018).

Conclusions

This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.

Section snippets

Material and Methods

With approval from our Partners Human Research Committee, we identified 115 consecutive patients who underwent surgical pulmonary embolectomy at our institution between October 1999 and September 2013. We use a multidisciplinary approach to evaluate all patients with suspected or confirmed PE that includes the early involvement of cardiology, cardiac surgery, and chest radiology teams. The diagnosis of acute PE was made by chest computed tomography angiography in 96 of 115 patients (83%; Fig 1

Results

The study population had a mean age of 59 years (± 13) and included 43 women (37.4%). The most common presenting symptom was dyspnea (98 of 115, 85%), and less common were chest pain (28 of 115, 24%) and syncope (18 of 115, 16%). Mean body mass index was 29.5 ± 6.2 kg/m2. Preoperative risk factors are listed in Table 1.

Comment

According to current American Heart Association and American College of Chest Physicians guidelines, thrombolysis remains the mainstay choice for acute, massive PE, as well as for select patients with submassive PE 9, 10. The principal finding of our study, one of the largest to date, is that surgical pulmonary embolectomy is safe and effective, and should play a broader role in the initial treatment of acute PE. We achieved an overall operative mortality of 6.9% by intervening in patients with

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