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Rahouma M, Al-Thani S, Salem H, Mahmoud A, Khairallah S, Shenouda D, Sultan B, Khalil L, Alomari M, Ali M, Makey IA, Haney JC, Mick S, El-Sayed Ahmed MM. The Outcomes of Surgical Pulmonary Embolectomy for Pulmonary Embolism: A Meta-Analysis. J Clin Med 2024; 13:4076. [PMID: 39064116 PMCID: PMC11278425 DOI: 10.3390/jcm13144076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2024] [Revised: 07/04/2024] [Accepted: 07/06/2024] [Indexed: 07/28/2024] Open
Abstract
Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify articles reporting SPE for pulmonary embolism. The outcomes included in-hospital and long-term mortality in addition to postoperative morbidities. The random effect inverse variance method was used. Cumulative meta-analysis, leave-one-out sensitivity analysis, subgroup analysis and meta-regression were performed. Results: Among the 1949 searched studies in our systematic literature search, 78 studies met our inclusion criteria, including 6859 cases. The mean age ranged from 42 to 65 years. The percentage of males ranged from 25.6% to 86.7%. The median rate of preoperative cardiac arrest was 27.6%. The percentage of contraindications to preoperative systemic thrombolysis was 30.4%. The preoperative systemic thrombolysis use was 11.5%. The in-hospital mortality was estimated to be 21.96% (95% CI: 19.21-24.98); in-hospital mortality from direct cardiovascular causes was estimated to be 16.05% (95% CI: 12.95-19.73). With a weighted median follow-up of 3.05 years, the late cardiovascular and non-cardiovascular mortality incidence rates were 0.39 and 0.90 per person-year, respectively. The incidence of pulmonary bleeding, gastrointestinal bleeding, surgical site bleeding, non-surgical site bleeding and wound complications was 0.62%, 4.70%, 4.84%, 5.80% and 7.2%, respectively. Cumulative meta-analysis showed a decline in hospital mortality for SPE from 42.86% in 1965 to 20.56% in 2024. Meta-regression revealed that the publication year and male sex were associated with lower in-hospital mortality, while preoperative cardiac arrest, the need for inotropes or vasopressors and preoperative mechanical ventilation were associated with higher in-hospital mortality. Conclusions: This study demonstrates acceptable perioperative mortality rates and late cardiovascular and non-cardiovascular mortality in patients who undergo SPE for massive or submassive pulmonary embolism.
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Affiliation(s)
- Mohamed Rahouma
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY 10065, USA; (S.A.-T.); (S.K.); (S.M.)
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 11796, Egypt
| | - Shaikha Al-Thani
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY 10065, USA; (S.A.-T.); (S.K.); (S.M.)
| | - Haitham Salem
- Ain Shams University Hospital, Ain Shams University, Cairo 11517, Egypt;
| | - Alzahraa Mahmoud
- Faculty of Medicine, Beni Suef University, Beni Suef 2721562, Egypt;
| | - Sherif Khairallah
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY 10065, USA; (S.A.-T.); (S.K.); (S.M.)
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 11796, Egypt
| | - David Shenouda
- New York Institute of Technology, New York, NY 10023, USA;
| | - Batool Sultan
- Rak Medical and Health Sciences University, Ras al Khaimah 11172, United Arab Emirates;
| | | | - Mohammad Alomari
- Cardiothoracic Surgery Department, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.); (M.A.); (I.A.M.); (J.C.H.)
| | - Mostafa Ali
- Cardiothoracic Surgery Department, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.); (M.A.); (I.A.M.); (J.C.H.)
| | - Ian A. Makey
- Cardiothoracic Surgery Department, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.); (M.A.); (I.A.M.); (J.C.H.)
| | - John C. Haney
- Cardiothoracic Surgery Department, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.); (M.A.); (I.A.M.); (J.C.H.)
| | - Stephanie Mick
- Cardiothoracic Surgery Department, Weill Cornell Medicine, New York, NY 10065, USA; (S.A.-T.); (S.K.); (S.M.)
| | - Magdy M. El-Sayed Ahmed
- Cardiothoracic Surgery Department, Mayo Clinic, Jacksonville, FL 32224, USA; (M.A.); (M.A.); (I.A.M.); (J.C.H.)
- Surgery Department, Faculty of Medicine, Zagazig University, Zagazig 44519, Egypt
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Haft JW, Yost G. Open Surgical Treatment of Acute and Chronic Pulmonary Embolism. Interv Cardiol Clin 2023; 12:339-347. [PMID: 37290838 DOI: 10.1016/j.iccl.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Acute pulmonary embolism (PE) is a common cause of death and morbidity in the United States and the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH), a possible sequela of PE, has increased during the past decade. The mainstay treatment of CTEPH is open pulmonary endarterectomy, a procedure performed under hypothermic circulatory arrest, which entails endarterectomy of the branch, segmental and subsegmental pulmonary arteries. Acute PE may be similarly be treated with an open embolectomy in certain select circumstances.
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Affiliation(s)
- Jonathan W Haft
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA.
| | - Gardner Yost
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA
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3
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Porres-Aguilar M, Rivera-Lebron BN, Anaya-Ayala JE, León MCGD, Mukherjee D. Perioperative Acute Pulmonary Embolism: A Concise Review with Emphasis on Multidisciplinary Approach. Int J Angiol 2020; 29:183-188. [PMID: 33149540 PMCID: PMC7599112 DOI: 10.1055/s-0040-1709501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Perioperative acute pulmonary embolism represents a relatively rare complication; however, it could be very serious and devastating in some cases. Its diagnosis could be particularly challenging, especially in the intraoperative period. Herein, we emphasize some key concepts with the aim to perform an early and appropriate risk stratification, diagnostic and therapeutic approach in a multidisciplinary fashion, a brief overview on thromboprophylaxis, with the main objective to improve outcomes and survival in these challenging patients.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Adult Thrombosis Medicine, McGill University/Centre of Excellence of Thrombosis and Anticoagulation Care (CETAC), Jewish General Hospital, Montreal, Quebec, Canada
| | - Belinda N. Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, Pennsylvania
| | - Javier E. Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Department of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ), Ciudad de México, México
| | - María Cristina Guerrero de León
- Department of Internal Medicine and Intensive Care Unit; Hospital de Ginecologia y Obstetricia; UMAE 23; Instituto Mexicano del Seguro Social (IMSS); Monterrey, Mexico
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center, El Paso, Texas
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Tagawa T, Sakuraba S. Acute massive pulmonary embolism treated by urgent pulmonary embolectomy: A case report. Clin Case Rep 2020; 8:1502-1505. [PMID: 32884783 PMCID: PMC7455419 DOI: 10.1002/ccr3.2913] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 03/26/2020] [Accepted: 04/10/2020] [Indexed: 11/07/2022] Open
Abstract
The management of acute massive pulmonary embolism presents a clinical challenge as currently there is no consensus for definitive treatment. Early decision-making regarding surgical intervention is essential when the risk of mortality is high.
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Affiliation(s)
- Tsuyoshi Tagawa
- Division of Clinical AnesthesiaMie University HospitalMieJapan
| | - Shigeki Sakuraba
- Department of AnesthesiologyClinical Care MedicineKanagawa Dental UniversityKanagawaJapan
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5
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Mkalaluh S, Szczechowicz M, Karck M, Szabo G. Twenty-year results of surgical pulmonary thromboembolectomy in acute pulmonary embolism. SCAND CARDIOVASC J 2019; 53:98-103. [DOI: 10.1080/14017431.2019.1600013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Sabreen Mkalaluh
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
| | - Gabor Szabo
- Department of Cardiac Surgery, Heart and Marfan Center, University of Heidelberg, Heidelberg, Germany
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6
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The implementation of a pulmonary embolism response team in the management of intermediate- or high-risk pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2019; 7:493-500. [PMID: 30930079 DOI: 10.1016/j.jvsv.2018.11.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/15/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Massive and submassive pulmonary embolism (PE) can be life-threatening. Treatment options include anticoagulation, fibrinolysis, catheter-directed or open surgical thrombus removal, and extracorporeal membrane oxygenation. With increasing patient complexity and advanced therapeutic options, the approach to optimal care for patients with intermediate- to high-risk PE is not clearly established. Multidisciplinary, rapid response teams can optimize risk stratification and expedite management. A PE response team (PERT) composed of specialists from cardiology, vascular surgery, emergency medicine, pulmonary and critical care, interventional radiology, cardiac surgery, hospital medicine, and pharmacy was created at our institution. The team is tasked with evaluating and treating patients with massive and submassive PE by use of a risk stratification and treatment algorithm. We describe our initial experience with this approach. METHODS The records of patients treated by the PERT since inception in October 2015 through May 2017 were reviewed (intervention group). The diagnoses codes of the PERT patients were retrieved from the Vizient database. A retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, sex), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ2 statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant. RESULTS During the time interval, 77 patients with massive or submassive PE were treated by PERT activation; 992 patients included in the control group were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups despite higher use of interventional treatment modalities in the PERT group. CONCLUSIONS In our institution, assembly of a dedicated team to treat patients with massive or submassive PE according to a clinical algorithm resulted in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay were reduced by this approach, with no impact on direct cost despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.
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Surgical pulmonary embolectomy and catheter-based therapies for acute pulmonary embolism: A contemporary systematic review. J Thorac Cardiovasc Surg 2018; 156:2155-2167. [DOI: 10.1016/j.jtcvs.2018.05.085] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 05/07/2018] [Accepted: 05/10/2018] [Indexed: 12/26/2022]
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8
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Moriarty JM, Edwards M, Plotnik AN. Intervention in Massive Pulmonary Embolus: Catheter Thrombectomy/Thromboaspiration versus Systemic Lysis versus Surgical Thrombectomy. Semin Intervent Radiol 2018; 35:108-115. [PMID: 29872246 DOI: 10.1055/s-0038-1642039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Massive pulmonary embolus (PE), defined as hemodynamic shock from acute PE, is a life-threatening condition. Deaths from massive PE, especially when unsuspected, occur within minutes to hours of onset and as such prompt intervention can be lifesaving. Acute massive PE patients have traditionally been candidates for treatment with intravenous systemic thrombolysis to improve pulmonary artery pressure, arteriovenous oxygenation, and pulmonary perfusion in an effort to reduce mortality. However, patients with contraindications to systemic thrombolysis or those who have failed thrombolysis may benefit from other techniques including endovascular and surgical embolectomy. This article will review the current medical management as well as catheter-directed therapies and surgical embolectomy in the treatment of patients with massive PE.
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Affiliation(s)
- John M Moriarty
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Martin Edwards
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Adam N Plotnik
- Division of Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine at UCLA, Los Angeles, California
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Seo WW, Kim SE, Park MS, Lee JH, Park DG, Han KR, Oh DJ. Systematic Review of Treatment for Trapped Thrombus in Patent Foramen Ovale. Korean Circ J 2017; 47:776-785. [PMID: 28955396 PMCID: PMC5614954 DOI: 10.4070/kcj.2016.0295] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 12/22/2016] [Accepted: 01/12/2017] [Indexed: 12/20/2022] Open
Abstract
Background and Objectives Trapped thrombus in patent foramen ovale (PFO) is a rare complication of pulmonary embolism that may lead to tragic clinical events. The aim of this study was to identify the optimal treatment for different clinical situations in patients with trapped thrombus in a PFO by conducting a literature review. Subjects and Methods A PubMed database search was conducted from 1991 through 2015, and 194 patients (185 articles) with trapped thrombus in a PFO were identified. Patient characteristics, paradoxical embolic events, and factors affecting 60-day mortality were analyzed retrospectively. Results Among all patients, 112 (57.7%) were treated with surgery, 28 with thrombolysis, and 54 with anticoagulation alone. Dyspnea (79.4%), chest pain (33.0%), and syncope (17.5%) were the most common presenting symptoms. Pretreatment embolism was found in 37.6% of cases, and stroke (24.7%) was the most common event. Surgery was associated with fewer post-treatment embolic events than were other treatment options (p=0.044). In the multivariate analysis, initial shock or arrest, and thrombolysis were independent predictors of 60-day mortality. Thrombolysis was related with higher 60-day mortality compared with surgery in patients who had no initial shock or arrest. Conclusion This systematic review showed that surgery was associated with a lower overall incidence of post-treatment embolic events and a lower 60-day mortality in patients with trapped thrombus in a PFO. In patients without initial shock or arrest, thrombolysis was related with a higher 60-day mortality compared with surgery.
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Affiliation(s)
- Won-Woo Seo
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sung Eun Kim
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Myung-Soo Park
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jun-Hee Lee
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dae-Gyun Park
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Kyoo-Rok Han
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Dong-Jin Oh
- Division of Cardiology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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10
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Surgical Embolectomy for Acute Pulmonary Embolism: Systematic Review and Comprehensive Meta-Analyses. Ann Thorac Surg 2017; 103:982-990. [DOI: 10.1016/j.athoracsur.2016.11.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 09/26/2016] [Accepted: 11/02/2016] [Indexed: 12/16/2022]
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Lilje C, Chauhan A, Turner JP, Carson TH, Velez MC, Arcement C, Caspi J. Pediatric Pulmonary Embolism: Diagnostic and Management Challenges. World J Pediatr Congenit Heart Surg 2016; 9:110-113. [PMID: 27619327 DOI: 10.1177/2150135116663698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A rare case of massive pulmonary embolism is presented in an oligosymptomatic teenager with predisposing factors. Computed tomography pulmonary angiography supported by three-dimensional reconstruction was diagnostic. The embolus qualified as massive by conventional anatomical guidelines, but as low risk by more recent functional criteria. Functional assessment has complemented morphologic assessment for risk stratification in adult patients. Such evidence is scarce in pediatrics. The patient underwent surgical embolectomy, followed by prophylactic anticoagulation, without further events. Diagnostic and management challenges are discussed.
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Affiliation(s)
- Christian Lilje
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Aman Chauhan
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Jason P Turner
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Thomas H Carson
- 2 Department of Pathology, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
| | - Maria C Velez
- 1 Department of Pediatrics, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Christopher Arcement
- 3 Department of Radiology, Louisiana State University Health Sciences Center School of Medicine, Children's Hospital, New Orleans, LA, USA
| | - Joseph Caspi
- 4 Department of Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, LA, USA
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Kipfmueller F, Quiroz R, Goldhaber SZ, Schoepf UJ, Costello P, Kucher N. Chest CT assessment following thrombolysis or surgical embolectomy for acute pulmonary embolism. Vasc Med 2016; 10:85-9. [PMID: 16013191 DOI: 10.1191/1358863x05vm610oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Right ventricular (RV) enlargement, assessed by two-dimensional reconstructed 4-chamber views on contrast-enhanced multirow detector computed tomography (MDCT), is emerging as an important marker for predicting adverse clinical events in patients with acute pulmonary embolism (PE). It is unclear whether dynamic changes occur on chest computed tomography (CT) in response to thrombolysis or embolectomy to treat acute PE. We retrospectively investigated 23 consecutive patients who met the criteria of (1) a positive MDCT PE protocol; (2) RV dysfunction on echocardiography; (3) reperfusion therapy by systemic thrombolysis (n = 17) or surgical embolectomy (n = 6); and (4) follow-up MDCT study after completion of therapy. Two blinded observers reconstructed 4-chamber views on a Leonardo™ (Siemens, Munich, Germany) workstation using multiplanar reformats of axial CT data and then measured right and left ventricular dimensions (RVD, LVD). RV enlargement was defined as RVD/LVD ≥ 0.9. Mean age was 52 years, and there were 10 (43%) women. The median time to MDCT follow-up was 21 (range 2-231) days. Seventeen (74%) patients had their chest MDCT follow-up within 30 days. All 23 patients had RV enlargement (mean RVD/LVD 1.28, range 0.94 to 1.74) prior to initiation of reperfusion therapy. Although right ventricular enlargement was found in 43% of patients at follow-up, the mean RVD/LVD decreased from 1.28 ± 0.21 cm to 0.94 ± 0.16 cm (p = 0.001). The mean change in RVD/LVD was 0.31 ± 0.42 in thrombolysis patients and 0.42 ± 0.09 in embolectomy patients (p = 0.33). Reconstructed 4-chamber views on chest CT provide noninvasive imaging of right ventricular enlargement and permit dynamic assessment of the right ventricular response to thrombolysis and embolectomy in patients with acute PE.
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Affiliation(s)
- Florian Kipfmueller
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Jaber WA, Fong PP, Weisz G, Lattouf O, Jenkins J, Rosenfield K, Rab T, Ramee S. Acute Pulmonary Embolism: With an Emphasis on an Interventional Approach. J Am Coll Cardiol 2016; 67:991-1002. [PMID: 26916490 DOI: 10.1016/j.jacc.2015.12.024] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 11/17/2015] [Accepted: 12/14/2015] [Indexed: 12/31/2022]
Abstract
Compared with recent advances in treatment of serious cardiovascular diseases, such as myocardial infarction and stroke, the treatment and outcome of acute pulmonary embolism (PE) have remained relatively unchanged over the last few decades. This has prompted several experts to call for the formation of multidisciplinary PE response teams with a more proactive approach to the treatment of PE. In the current document, we discuss the formation of such teams and describe the available treatment options beyond anticoagulation, with a focus on the interventional approach. Acknowledging the paucity of data to support widespread adoption of such techniques, we call for the collection of outcomes data in multicenter registries and support for randomized trials to evaluate interventional treatments in patients with high-risk PE.
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Affiliation(s)
- Wissam A Jaber
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Pete P Fong
- Vanderbilt Heart and Vascular Institute, Nashville, Tennessee
| | - Giora Weisz
- Division of Cardiology, Shari Zadek Medical Center, Jerusalem, Israel
| | - Omar Lattouf
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Kenneth Rosenfield
- Section of Vascular Medicine, & Intervention, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Tanveer Rab
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
| | - Stephen Ramee
- Structural and Valvular Heart Disease Program, Ochsner Medical Center, New Orleans, Louisiana
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14
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Amirghofran AA, Emami Nia A, Javan R. Surgical Embolectomy in Acute Massive Pulmonary Embolism. Asian Cardiovasc Thorac Ann 2016; 15:149-53. [PMID: 17387199 DOI: 10.1177/021849230701500214] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute pulmonary embolism is a serious condition and despite diagnostic and therapeutic advances, mortality is still high. Anticoagulation, thrombolytic therapy, catheter embolectomy, and open pulmonary embolectomy are therapeutic options. Surgical embolectomy was considered the management of last resort, but recent studies show the effectiveness of this therapeutic modality. We reviewed our 7-year experience of pulmonary embolectomy in patients with acute massive pulmonary embolism from 1997 to 2004. Eleven patients underwent open embolectomy, 7 (64%) were male, and the mean age was 45.6 years. Pulmonary embolism occurred after major surgery in 5 patients (46%), 2 were diagnosed with malignancy and spinal cord injury, and no risk factors were detected in 4. The diagnosis was made by spiral computed tomography alone in 4 patients, and by angiography in 7. Cardiac arrest occurred in 3 patients preoperatively; 2 of them survived. Open pulmonary embolectomy is the most effective treatment for acute massive pulmonary embolism. Cardiac arrest is the worst prognostic factor. Less aggressive clot evacuation in patients who are diagnosed late appears to be effective in minimizing postoperative hemoptysis.
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Affiliation(s)
- Ahmad A Amirghofran
- Department of Cardiac Surgery, Shiraz University of Medical Sciences, Faghihi Hospital, Shiraz, Iran.
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15
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Management of deep vein thrombosis and pulmonary embolism (venous thromboembolism) during pregnancy. Gen Thorac Cardiovasc Surg 2016; 64:309-14. [DOI: 10.1007/s11748-016-0635-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 02/25/2016] [Indexed: 10/22/2022]
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Surgical Treatment of Acute Massive Pulmonary Embolism. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:75-88. [DOI: 10.1007/5584_2016_107] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Azari A, Beheshti AT, Moravvej Z, Bigdelu L, Salehi M. Surgical embolectomy versus thrombolytic therapy in the management of acute massive pulmonary embolism: Short and long-term prognosis. Heart Lung 2015; 44:335-9. [PMID: 26077690 DOI: 10.1016/j.hrtlng.2015.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 04/12/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Comparison between surgical embolectomy and thrombolytic therapy in patients suffering from acute massive pulmonary embolism (AMPE). BACKGROUND Prompt treatment of AMPE is necessary, although optimal management is a matter of debate. METHODS Patients with AMPE were assigned to either thrombolytic therapy or pulmonary surgical embolectomy. Early and late mortality, systolic pulmonary artery pressure (SPAP), right ventricular diameter (RVD) and bleeding complications were evaluated. RESULTS Seventy eight patients were treated with thrombolytic therapy and 30 patients underwent surgery. The difference between pre-intervention and third-day post-intervention in terms of RVD and SPAP was significantly greater in patients under surgical embolectomy (P < 0.001). There was a significant decline in RVD and SPAP in both groups during follow-up (P < 0.001). Mortality rate in the surgical embolectomy group was lower than the thrombolytic group although not significantly. CONCLUSION Early surgical treatment was associated with fewer complications in comparison to thrombolytic therapy.
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Affiliation(s)
- Ali Azari
- Department of Cardiac Surgery, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ahmad Tashakori Beheshti
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Moravvej
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Students Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Bigdelu
- Member of Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Cardiology, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Maryam Salehi
- Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Davies MG, El-Sayed HF. Current Status of Clot Removal for Acute Pulmonary Embolism. Ann Vasc Surg 2015; 31:211-20. [PMID: 26597237 DOI: 10.1016/j.avsg.2015.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Accepted: 08/08/2015] [Indexed: 11/25/2022]
Abstract
Acute pulmonary embolism (PE) continues to carry a high mortality if not recognized early and treated aggressively. Rapid recognition and diagnosis remains the mainstay of all efforts. Risk stratification early is paramount to guide therapy and achieve successful outcomes. Pulmonary emboli can generally be classified as massive, submassive, or stable. Fibrinolysis and/or surgical embolectomy are recommended for the treatment of the patient with massive PE to rescue the patient and restore hemodynamic stability. Current trials support an aggressive approach. In submassive PE, determination of right ventricular (RV) strain by echocardiography and biomarker assessment (troponin and B-type natriuretic peptide) identify patients who can benefit from catheter-directed therapy with the therapeutic intent of achieving a rapid reduction of RV afterload, prevention of impending hemodynamic collapse and prolonged in-hospital and outpatient survival. Current trials have not shown long-term benefit for this approach to date, and thus, this therapy should only be offered to select patients. Stable PE can be treated using both an inpatient and an outpatient approach, based on the available infrastructure. Therapy for PE continues to evolve and stratification of risks and benefits remain the key to implementation of invasive strategies.
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Affiliation(s)
- Mark G Davies
- South Texas Center for Vascular Care, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, TX.
| | - Hosam F El-Sayed
- Division of Vascular Diseases and Surgery, Ohio State University, Columbus, OH
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Abstract
Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and submassive pulmonary embolism.
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Worku B, Gulkarov I, Girardi LN, Salemi A. Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism. Cardiology 2014; 129:106-10. [DOI: 10.1159/000363647] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/11/2014] [Indexed: 11/19/2022]
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21
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Kanjirakadavath B, Krishnan MN, Vinayakumar D, Raju D, Nithin PG, Rajesh KF, Sreekumar P. A floating right heart thrombus in transit across tricuspid valve causing an endocardial friction rub. Indian Heart J 2013; 65:457-9. [PMID: 23993010 DOI: 10.1016/j.ihj.2013.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2012] [Revised: 03/20/2013] [Accepted: 06/19/2013] [Indexed: 11/26/2022] Open
Abstract
We report a 42-year-old lady on combined oral contraceptive pills with deep venous thrombosis and mild pulmonary embolism, who developed shock, while being treated with heparin. On auscultation, there was an unexpected loud, superficial, squeaky, triphasic friction rub over the left lower parasternal area. Simultaneous echocardiogram revealed a large serpiginous, freely floating mass in right atrium, prolapsing freely to right ventricular inlet across the tricuspid valve. The endocardial friction rub persisted for about 24 h as long as the thrombus was intracardiac and disappeared when the thrombus disappeared from right heart, occluding the proximal left pulmonary artery. She died due to shock awaiting surgery. We highlight that such a rub in a patient with deep venous thrombosis, though rare, may be an important clue to impending pulmonary embolism.
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Zochios VA, Keeshan A. Pulmonary Embolism in the Mechanically-Ventilated Critically Ill Patient: Is it Different? J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pulmonary embolism (PE) confers significant in-hospital morbidity and mortality, and critically ill patients remain at risk for venous thromboembolism despite thromboprophylaxis. Recognition of the clinical manifestations and immediate management of PE are of paramount importance. Despite diagnostic advances, PE is often undiagnosed and untreated in patients receiving mechanical ventilation, as these patients do not exhibit the common clinical features of the condition, making the diagnosis very challenging. Computed tomographic pulmonary angiography is probably the reference standard for the diagnosis of acute PE in the haemodynamically stable, ventilated patient. In the setting of circulatory collapse, bedside echocardiography may be used to risk stratify these patients, based on the presence or absence of right ventricular dysfunction, and guide further management. Treatment options include anticoagulation alone, anticoagulation plus thrombolysis, surgical or catheter embolectomy. Inotropes, vasopressors and pulmonary artery vasodilators may be considered after initial resuscitation of the right ventricle. Few studies have focused on estimating the prevalence of PE among mechanically-ventilated intensive care unit (ICU) patients and there is notable lack of data assessing predictive factors, prevention, diagnostic strategy and management of PE in the ICU setting.
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Affiliation(s)
- Vasileios A Zochios
- ACCS Anaesthesia Core Trainee, East Midlands (South) School of Anaesthesia, University Hospitals of Leicester NHS Trust
| | - Alex Keeshan
- Consultant Intensivist, University Hospitals of Leicester NHS Trust, Leicester General Hospital
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M. Lattouf O, Leeper K, Kelli H. Life-Threatening Pulmonary Embolism: A Multidisciplinary Approach to Diagnosis and Management. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/wjcs.2013.36038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Sekhri V, Mehta N, Rawat N, Lehrman SG, Aronow WS. Management of massive and nonmassive pulmonary embolism. Arch Med Sci 2012; 8:957-69. [PMID: 23319967 PMCID: PMC3542486 DOI: 10.5114/aoms.2012.32402] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 04/15/2012] [Accepted: 04/20/2012] [Indexed: 11/20/2022] Open
Abstract
Massive pulmonary embolism (PE) is characterized by systemic hypotension (defined as a systolic arterial pressure < 90 mm Hg or a drop in systolic arterial pressure of at least 40 mm Hg for at least 15 min which is not caused by new onset arrhythmias) or shock (manifested by evidence of tissue hypoperfusion and hypoxia, including an altered level of consciousness, oliguria, or cool, clammy extremities). Massive pulmonary embolism has a high mortality rate despite advances in diagnosis and therapy. A subgroup of patients with nonmassive PE who are hemodynamically stable but with right ventricular (RV) dysfunction or hypokinesis confirmed by echocardiography is classified as submassive PE. Their prognosis is different from that of others with non-massive PE and normal RV function. This article attempts to review the evidence-based risk stratification, diagnosis, initial stabilization, and management of massive and nonmassive pulmonary embolism.
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Affiliation(s)
- Vishal Sekhri
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Nimeshkumar Mehta
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Naveen Rawat
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Stuart G. Lehrman
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Divisions of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Cardiology, New York Medical College, Valhalla, NY, USA
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He C, Von Segesser LK, Kappetein PA, Mestres CA, Smith JA, Choong CKC. Acute pulmonary embolectomy. Eur J Cardiothorac Surg 2012; 43:1087-95. [DOI: 10.1093/ejcts/ezs605] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Takahashi H, Okada K, Matsumori M, Kano H, Kitagawa A, Okita Y. Aggressive surgical treatment of acute pulmonary embolism with circulatory collapse. Ann Thorac Surg 2012; 94:785-91. [PMID: 22698769 DOI: 10.1016/j.athoracsur.2012.03.101] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 02/27/2012] [Accepted: 03/01/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Acute high-risk pulmonary embolism is a life-threatening condition with high early mortality rates resulting from acute right ventricular failure and cardiogenic shock. We retrospectively analyzed the outcomes of surgical embolectomy among patients with circulatory collapse. METHODS Between July 2000 and September 2011, 24 consecutive patients (17 women and 7 men; mean age, 59.9±17.2 years) underwent emergency surgical embolectomy to treat acute pulmonary embolism with circulatory collapse. Nineteen (79.2%) patients were in cardiogenic shock, and 16 (66.7%) patients received preoperative percutaneous cardiopulmonary support. Eleven (45.8%) patients were in cardiac arrest. The preoperative pulmonary artery obstruction index was 76.9%±16.4% (median, 88.9%; range, 44.4%-88.9%). The indications for surgical intervention were cardiogenic shock (n=16 [66.7%]), failed medical therapy or catheter embolectomy (n=4 [16.7%]), or contraindication for thrombolysis (n=4 [16.7%]). Follow-up was 100% complete with a mean of 6.8±3.9 years (median, 5.6 years). RESULTS The in-hospital mortality rate was 12.5% (n=3). One patient underwent a repeated embolectomy on postoperative day 6. The postoperative course was complicated by cerebral infarction and by mediastinitis in 1 patient each. The 5-year cumulative survival rate was 87.5%±6.8%. Mean right ventricular pressure significantly decreased from 66.9 to 28.5 mm Hg among the survivors. CONCLUSIONS Surgical pulmonary embolectomy is an excellent approach to treating acute pulmonary embolism with circulatory collapse. Providing immediate percutaneous cardiopulmonary support to patients with cardiogenic shock could help to resuscitate and stabilize cardiopulmonary function and allow for a good outcome of pulmonary embolectomy.
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Affiliation(s)
- Hiroaki Takahashi
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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27
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Garg P, Jain A, Kumar A, Chugh R. Surgical pulmonary embolectomy for submassive pulmonary embolism: a case report and review of the literature. Indian J Thorac Cardiovasc Surg 2012. [DOI: 10.1007/s12055-012-0139-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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28
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Hashiba K, Okuda J, Maejima N, Iwahashi N, Tsukahara K, Tahara Y, Hibi K, Kosuge M, Ebina T, Endo T, Umemura S, Kimura K. Percutaneous cardiopulmonary support in pulmonary embolism with cardiac arrest. Resuscitation 2012; 83:183-7. [DOI: 10.1016/j.resuscitation.2011.10.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 09/09/2011] [Accepted: 10/31/2011] [Indexed: 11/26/2022]
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29
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Ando T, Abe H, Nagata T, Sakurai Y, Chikada M, Kobayashi T, Makuuchi H. Reports of four surgical treatments of acute pulmonary embolism with a floating thrombus in the right atrium. Gen Thorac Cardiovasc Surg 2011; 59:705-8. [PMID: 21984139 DOI: 10.1007/s11748-010-0732-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2010] [Accepted: 09/18/2010] [Indexed: 11/30/2022]
Abstract
Acute pulmonary embolism (APE) is a serious disease. Recently, multidetector-row computed tomography (MDCT) has proven to be valuable in detecting APE and deep vein thrombosis. APE is classified as massive, submassive, and nonmassive. The incidence of submassive APE and the number of therapeutic approaches for clinically diagnosed critical submassive APE have both increased. However, most strategies for submassive APE have been conservative, e.g., transvenous catheter pulmonary embolectomy, and there are few reports on surgical pulmonary embolectomy. We examined the surgical outcomes in four cases of submassive APE with a floating thrombus in the right atrium (RA) from August 2003 to July 2008. All patients appeared to have no neurological complications and showed an event-free survival of up to 65 months (37 ± 25 months). Surgical pulmonary embolectomy was effective for submassive APE with a floating thrombus in the RA.
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Affiliation(s)
- Takashi Ando
- Department of Cardiovascular Surgery, St. Marianna University School of Medicine, Sugao-ku, Kawasaki, Kanagawa, Japan
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30
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Treatment of pulmonary embolism: anticoagulation, thrombolytic therapy, and complications of therapy. Crit Care Clin 2011; 27:825-39, vi. [PMID: 22082516 DOI: 10.1016/j.ccc.2011.08.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
During the last two decades, considerable progress in technology and clinical research methods have led to advances in the approach to the diagnosis, prevention, and treatment of acute venous thromboembolism (VTE). Despite this, however, the diagnosis is often delayed and preventive methods are often ignored. Thus, the morbidity and mortality associated with VTE remain high. The therapeutic approach to acute VTE is discussed in this article, with a particular focus on the intensive care unit setting.
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31
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Guidelines for the diagnosis, treatment and prevention of pulmonary thromboembolism and deep vein thrombosis (JCS 2009). Circ J 2011; 75:1258-81. [PMID: 21441695 DOI: 10.1253/circj.cj-88-0010] [Citation(s) in RCA: 220] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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32
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Perioperative pulmonary embolism: diagnosis and anesthetic management. J Clin Anesth 2011; 23:153-65. [DOI: 10.1016/j.jclinane.2010.06.011] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/18/2010] [Accepted: 06/29/2010] [Indexed: 12/17/2022]
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33
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Samoukovic G, Malas T, de Varennes B. The role of pulmonary embolectomy in the treatment of acute pulmonary embolism: a literature review from 1968 to 2008☆. Interact Cardiovasc Thorac Surg 2010; 11:265-70. [DOI: 10.1510/icvts.2009.228361] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Jean N, Labombarda F, De La Gastine G, Raisky O, Boudjemline Y. Successful pulmonary embolectomy in a 4-year-old girl with antithrombin III deficiency. Pediatr Cardiol 2010; 31:711-3. [PMID: 20143056 DOI: 10.1007/s00246-010-9653-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Accepted: 01/19/2010] [Indexed: 11/26/2022]
Abstract
We report the case of a 4-year-old girl, successfully treated by surgical pulmonary embolectomy for acute massive pulmonary embolism. She was known to have a congenital antithrombin III deficiency diagnosed after a familial history of thromboembolic events. Surgical embolectomy may be considered as a treatment option in selected patient with anatomically extensive pulmonary embolism.
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Affiliation(s)
- Nolwenn Jean
- Department of Pediatrics, CHU Cote de Nacre, Caen, France
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35
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Successful usage of extracorporeal membrane oxygenation as a bridge therapy for acute pulmonary embolism between hospitals. Gen Thorac Cardiovasc Surg 2010; 58:283-6. [DOI: 10.1007/s11748-009-0540-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 09/03/2009] [Indexed: 11/26/2022]
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36
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Uso de trombolíticos e alternativas terapêuticas no paciente grave. J Bras Pneumol 2010. [DOI: 10.1590/s1806-37132010001300012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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37
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Lazar HL, Farber HW. Early Pulmonary Embolectomy for Acute Pulmonary Embolus: An Operation Whose Time Has Come. J Card Surg 2010; 25:259-60. [DOI: 10.1111/j.1540-8191.2010.01012.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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38
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Carvalho EM, Macedo FIB, Panos AL, Ricci M, Salerno TA. Pulmonary Embolectomy: Recommendation for Early Surgical Intervention. J Card Surg 2010; 25:261-6. [DOI: 10.1111/j.1540-8191.2009.00986.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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39
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Stepanenko A, Potapov EV, Krabatsch T, Hetzer R. Right ventricular failure after left ventricular assist device implantation with concomitant pulmonary embolectomy needing right ventricular assist device support in a patient with terminal heart failure and asymptomatic pulmonary thrombus. Interact Cardiovasc Thorac Surg 2009; 10:154-5. [PMID: 19833639 DOI: 10.1510/icvts.2009.215962] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We present a case in which a left ventricular assist device (LVAD) was implanted in a patient with terminal heart failure and preoperatively diagnosed asymptomatic thrombus in the right pulmonary artery. LVAD implantation was performed with concomitant thromboembolectomy in deep hypothermic circulatory arrest (DHCA) and intra-operatively right ventricular assist device (RVAD) implantation for the treatment of acute right ventricular failure became necessary. The patient was weaned from the RVAD after eight days of support.
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Affiliation(s)
- Alexander Stepanenko
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany.
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40
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Fengler BT, Brady WJ. Fibrinolytic therapy in pulmonary embolism: an evidence-based treatment algorithm. Am J Emerg Med 2009; 27:84-95. [DOI: 10.1016/j.ajem.2007.10.021] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 10/26/2007] [Accepted: 10/27/2007] [Indexed: 10/21/2022] Open
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41
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Lee S, Song SW, Yi G, Youn YN, Yoo KJ, Chang BC. Open pulmonary thromboembolectomy in patients with major pulmonary thromboembolism. Yonsei Med J 2008; 49:973-7. [PMID: 19108021 PMCID: PMC2628032 DOI: 10.3349/ymj.2008.49.6.973] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
PURPOSE We retrospectively analyzed open pulmonary thromboembolectomy in patients with acute and chronic pulmonary thromboembolism. MATERIALS AND METHODS Between August 1990 and May 2005, 12 consecutive patients with acute and chronic pulmonary thromboembolism underwent open pulmonary thromboembolectomy at Yonsei Cardiovascular Center. Their mean age was 47.5 years, and 7 of the patients were female. Among 12 patients, 5 had acute onset, and 7 had chronic disease, and 9 patients were associated with deep venous thrombosis. Extent of pulmonary embolism was massive in 3 patients with hemodynamic instability, and submassive in 8 patients. Preoperative echocardiogram revealed elevated right ventricular pressure in all patients, and 7 patients were in NYHA functional class III or IV. Pulmonary thromboembolectomy was performed in all patients under total circulatory arrest. RESULTS There were 2 hospital deaths (16.7%). Among the patients who survived, mean right ventricular pressure was decreased significantly from 64.3 mmHg to 34.0 mmHg with improvement of NYHA functional class. CONCLUSION Open pulmonary thromboembolectomy is thought to be an immediate and definitive treatment for massive pulmonary embolism with optimal results. Even though operative mortality is still high, early diagnosis and immediate surgical intervention in highly selective patients may improve the clinical outcome.
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Affiliation(s)
- Sak Lee
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Gijong Yi
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Nam Youn
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Jong Yoo
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Byung-Chul Chang
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
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42
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Guías de práctica clínica sobre diagnóstico y manejo del tromboembolismo pulmonar agudo. Rev Esp Cardiol (Engl Ed) 2008. [DOI: 10.1016/s0300-8932(08)75741-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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43
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44
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Sádaba JR, Greco E, Alvarez LA, Pulitani I, Juaristi A, Goiti JJ. The Surgical Option in the Management of Acute Pulmonary Embolism. J Card Surg 2008; 23:729-32. [DOI: 10.1111/j.1540-8191.2008.00685.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | - Ernesto Greco
- Cirugía Cardiaca, Policlínica Gipuzkoa, San Sebastián, Spain
| | - Luis A. Alvarez
- Cirugía Cardiaca, Policlínica Gipuzkoa, San Sebastián, Spain
| | - Ivana Pulitani
- Cirugía Cardiaca, Policlínica Gipuzkoa, San Sebastián, Spain
| | | | - Juan J. Goiti
- Cirugía Cardiaca, Policlínica Gipuzkoa, San Sebastián, Spain
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45
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46
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Torbicki A, Perrier A, Konstantinides S, Agnelli G, Galiè N, Pruszczyk P, Bengel F, Brady AJB, Ferreira D, Janssens U, Klepetko W, Mayer E, Remy-Jardin M, Bassand JP. Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008; 29:2276-315. [PMID: 18757870 DOI: 10.1093/eurheartj/ehn310] [Citation(s) in RCA: 1193] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Non-thrombotic PE does not represent a distinct clinical syndrome. It may be due to a variety of embolic materials and result in a wide spectrum of clinical presentations, making the diagnosis difficult. With the exception of severe air and fat embolism, the haemodynamic consequences of non-thrombotic emboli are usually mild. Treatment is mostly supportive but may differ according to the type of embolic material and clinical severity.
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Affiliation(s)
- Adam Torbicki
- Department of Chest Medicine, Institute for Tuberculosis and Lung Diseases, Warsaw, Poland.
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47
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Sa YJ, Choi SY, Lee JH, Kwon JB, Moon SW, Jo KH, Wang YP, Kim SC, Kim PJ, Jung HO. Off-Pump Open Pulmonary Embolectomy for Patients with Major Pulmonary Embolism. Heart Surg Forum 2007; 10:E304-8. [PMID: 17599880 DOI: 10.1532/hsf98.20071043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Acute major pulmonary artery embolism (AMPE) requires rapid diagnosis and early intensive treatment to optimize patient outcomes. Most patients with AMPE and hemodynamic instability need open pulmonary embolectomy (OPE). We modified the technique of OPE to include a minimally invasive procedure without the use of cardiopulmonary bypass (CPB). From March 1988 to April 2006, we performed OPE on a total of 12 patients (21 sides) with AMPE. Seven patients (13 sides) underwent conventional OPE with CPB and 5 patients underwent off-pump OPE (OPPE), 4 (8 sides) with AMPE and 1 with catheter embolus with thrombosis. In patients who underwent conventional OPE, there was 1 hospital death in a patient with severe right ventricle dysfunction and 2 significant cases of airway bleeding. In patients who underwent OPPE, there was 1 case of minimal airway bleeding. Mean systolic pulmonary artery pressure in conventional OPE and OPPE patients, respectively, decreased from 50.3 +/- 14 mmHg and 35.4 +/- 6.6 mmHg pre-operatively to 41.7 +/- 20 and 28 +/- 3 mmHg postoperatively. During the long-term follow-up, there were 2 cancer-related deaths but no recurrence of PE. All surviving patients maintained functional class I (n = 10) or II (n = 1). Compared with conventional OPE, OPPE was effective for treating AMPE in our selected cases. Modification of conventional CPB and systemic full heparinization to minimal use of systemic heparinization without CPB may be helpful in treating selected patients with AMPE.
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Affiliation(s)
- Young Jo Sa
- Department of Thoracic and Cardiovascular Surgery, The Catholic University of Korea, Seoul, Republic of Korea.
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Abstract
Pulmonary embolism in the critically ill requires considerations beyond anticoagulant therapy. Measurements of chamber size by echocardiography and CT and of circulating biomarkers identify higher-risk patients with moderate accuracy and may aid determination of patient acuity. Preserving right ventricular function requires judicious use of volume administration, vasopressor, and perhaps vasodilator therapies. Obstructing thrombus can be treated with fibrinolytic drugs, percutaneous instrumentation, or surgically, but these treatments may not be equally effective or safe. Anticoagulant therapy in critically ill patients is likely best administered IV. Bleeding complications should be assiduously sought but do not necessitate anticoagulant discontinuation in every case. The antidotes protamine, desmopressin acetate, factor VIII inhibitory bypass activity, and recombinant factor VIIa may each have a place in controlling anticoagulant-related bleeding. The grave prognosis of heparin-induced thrombocytopenia warrants close surveillance, with rapid switching to lepirudin, argatroban, or fondaparinux necessary if it is suspected. Retrievable vena cava filters can be lifesaving, and at least one type may be safely removed after residence of nearly 1 year.
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Affiliation(s)
- David J Carlbom
- Pulmonary-Critical Care Medicine Division, University of Washington School of Medicine, Seattle, WA, USA
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Stein PD, Alnas M, Beemath A, Patel NR. Outcome of pulmonary embolectomy. Am J Cardiol 2007; 99:421-3. [PMID: 17261411 DOI: 10.1016/j.amjcard.2006.08.050] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2006] [Revised: 08/23/2006] [Accepted: 08/23/2006] [Indexed: 01/11/2023]
Abstract
In view of the importance of pulmonary embolectomy as a possible treatment option in highly compromised patients with acute pulmonary embolism, a systematic review of immediate surgical outcomes was performed. Pooled data from 46 reported case series of patients operated from 1961 to 2006 showed an average mortality of 389 of 1,300 patients (30%). In patients operated on before 1985, the average mortality was 32%, compared with 20% in patients operated from 1985 to 2005. In patients who experienced cardiac arrest before pulmonary embolectomy, the operative mortality was 59% compared with 29% in patients who did not have preoperative cardiac arrest. In conclusion, despite generally high mortality in patients who undergo pulmonary embolectomy, it may have life-saving potential in some instances.
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Affiliation(s)
- Paul D Stein
- St. Joseph Mercy Oakland Hospital, Pontiac, Michigan, USA.
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