1
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Robinson H, Anstey M, Litton E, Ho KM, Jacques A, Rathore K, Yap T, Lucas M, Worthy L, Tan JL, Yeoh M, Yau HC, Robinson K, Mudie J, Hennelly G, Wibrow B. Long-Term Echocardiographic and Clinical Outcomes After Invasive and Non-Invasive Therapies for Sub-Massive and Massive Acute Pulmonary Embolism. Heart Lung Circ 2024:S1443-9506(24)00197-5. [PMID: 38942622 DOI: 10.1016/j.hlc.2024.03.014] [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: 10/11/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 06/30/2024]
Abstract
AIM Acute pulmonary embolism (PE) is a significant cause of mortality in the hospital setting. The objective of this study was to outline the long-term outcomes after surgical and non-surgical management for patients with massive and submassive PE. METHODS Population cohort observational study evaluating all patients who presented to three tertiary hospitals in the state of Western Australia with access to cardiothoracic services over 5 years (2013-2018). Reviewed notes of all patients as well as radiology, linked mortality data and all available echocardiography studies at the primary hospital. RESULTS In total, 245 patients were identified, of which 41 received surgical management and 204 non-surgical management; demographic data was similar. Clinically, the surgical group had higher rates of shock requiring vasopressors, severe bradycardia, or cardiopulmonary resuscitation prior to intervention. The 28-day mortality was not statistically significantly different between the surgical embolectomy group (2/41 [4.2%]) and the non-surgical group (17/201 [8.3%]) (p=0.382). There was no difference in 12-month mortality, including when this was adjusted for vasopressors, right ventricular (RV) strain, troponin, and brain natriuretic peptide. In the massive PE sub-group, 28-day mortality was not significantly different: 2/29 (6.9%) surgical group vs 7/34 (20.2%) non-surgical group (p=0.064). Higher rates of severe RV impairment and dilatation were present in the surgical group. All patients with available echocardiography studies at outpatient follow-up returned to normal or mild RV impairment. CONCLUSION Patients who presented with massive or submassive PE had similar outcomes whether treated with surgical or non-surgical management. Surgical embolectomy is a safe option in a cardiothoracic centre setting.
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Affiliation(s)
- Hayley Robinson
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Curtin School of Public Health, Curtin University, Bentley, WA, Australia
| | - Edward Litton
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Department of Intensive Care, St John of God Healthcare, Subiaco, WA, Australia
| | - Kwok M Ho
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Medical School and School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA, Australia; Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Angela Jacques
- Institute of Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; Department of Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Kaushalendra Rathore
- Department of Cardiothoracics, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Timothy Yap
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Monique Lucas
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Laura Worthy
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jo-Lynn Tan
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Matthew Yeoh
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Ho-Cing Yau
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Kieran Robinson
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Jess Mudie
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Gavin Hennelly
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Bradley Wibrow
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia.
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2
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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024; 44:182-192. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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3
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [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: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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4
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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5
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Sasaki H, Kowatari R, Kondo N, Minakawa M. Simple and secure thrombectomy without circulatory arrest for acute pulmonary embolism. J Cardiothorac Surg 2024; 19:74. [PMID: 38331836 PMCID: PMC10854102 DOI: 10.1186/s13019-024-02535-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Surgical pulmonary artery thrombectomy is a well-established emergency treatment for massive pulmonary embolism (PE) in which fibrinolysis or thrombolysis are not effective. However, surgery for massive PE that requires peripheral pulmonary artery thrombus removal remains challenging. We established a simple and secure pulmonary artery thrombectomy method using cardiopulmonary bypass and cardiac arrest. In this procedure, the surgical assistant arm, typically used for coronary artery bypass grafting, is used to obtain a feasible working space during thrombectomy. CASE PRESENTATION We present seven consecutive massive PE cases that were treated with the present surgical method and successfully weaned from cardiopulmonary bypass or extracorporeal membrane oxygenation postoperatively. CONCLUSIONS This procedure can be used to prevent right ventricular failure after surgery as surgeons can remove the peripheral thrombus with clear vision up to the second branch of the pulmonary artery.
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Affiliation(s)
- Hanae Sasaki
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
| | - Ryosuke Kowatari
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan.
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
| | - Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine, 5 Zaifu-Cho, Hirosaki City, Aomori, 036-8562, Japan
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6
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Gorgis S, Yang BY, Zhen-Yu Tong M, Ghobrial J, Al-Jaghbeer MJ. Refractory Hypoxemia in Acute-on-Chronic Submassive Pulmonary Embolism. Ann Am Thorac Soc 2023; 20:1654-1658. [PMID: 37909794 DOI: 10.1513/annalsats.202302-126cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 08/17/2023] [Indexed: 11/03/2023] Open
Affiliation(s)
- Sarah Gorgis
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute
- Department of Critical Care, Respiratory Institute, and
| | - Benjamin Yuhwei Yang
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Michael Zhen-Yu Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joanna Ghobrial
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute
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7
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Goldberg JB, Giri J, Kobayashi T, Ruel M, Mittnacht AJC, Rivera-Lebron B, DeAnda A, Moriarty JM, MacGillivray TE. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e628-e647. [PMID: 36688837 DOI: 10.1161/cir.0000000000001117] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.
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8
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Assouline B, Assouline-Reinmann M, Giraud R, Levy D, Saura O, Bendjelid K, Combes A, Schmidt M. Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation? J Clin Med 2022; 11:4734. [PMID: 36012973 PMCID: PMC9409813 DOI: 10.3390/jcm11164734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39-115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.
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Affiliation(s)
- Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Marie Assouline-Reinmann
- Cardiology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière University Hospital, 75013 Paris, France
| | - Raphaël Giraud
- Intensive Care Unit, Geneva University Hospitals, 1205 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, 1205 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Alain Combes
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, 75013 Paris, France
| | - Matthieu Schmidt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, 75013 Paris, France
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9
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Liu Z, Chen J, Xu X, Lan F, He M, Shao C, Xu Y, Han P, Chen Y, Zhu Y, Huang M. Extracorporeal Membrane Oxygenation—First Strategy for Acute Life-Threatening Pulmonary Embolism. Front Cardiovasc Med 2022; 9:875021. [PMID: 35722115 PMCID: PMC9203845 DOI: 10.3389/fcvm.2022.875021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background Both venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm. Methods This study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021. Results Mean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively. Conclusions An ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy. Type of Research Single-center retrospective review of a prospectively maintained registry.
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Affiliation(s)
- Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Zhenjie Liu
| | - Jinyi Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Fen Lan
- Department of Respiratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minzhi He
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Changming Shao
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yongshan Xu
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Pan Han
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yibing Chen
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yongbin Zhu
- Medical Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Yongbin Zhu
| | - Man Huang
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Man Huang
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10
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Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
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Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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11
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Lin DSH, Lin YS, Lee JK, Chen WJ. Short- and Long-Term Outcomes of Catheter-Directed Thrombolysis versus Pulmonary Artery Embolectomy in Pulmonary Embolism: A National Population-Based Study. J Endovasc Ther 2021; 29:409-419. [PMID: 34706585 DOI: 10.1177/15266028211054763] [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: 11/16/2022]
Abstract
OBJECTIVES This study aimed to compare the short-term and long-term follow-up outcomes of catheter-directed thrombolysis (CDT) with those of pulmonary artery embolectomy (PAE) for patients with acute pulmonary embolism (PE) included in a nationwide cohort. BACKGROUND Data allowing direct comparisons between CDT and PAE are lacking in the literature, and the optimal management of high-risk and intermediate-risk PE is still debated. METHODS A retrospective cohort study was conducted with data for 2001 through 2013 collected from the Taiwan National Health Insurance Research Database (NHIRD). Patients who were first admitted for PE and treated with either CDT or PAE were included and compared. In-hospital outcomes included in-hospital death and safety (bleeding and cardiac arrhythmias) outcomes. Follow-up outcomes included all-cause mortality and recurrent PE during the 1- and 2-year follow-up periods and through the last follow-up. Inverse probability of treatment weighting (IPTW) based on the propensity score was used to minimize possible selection bias, including indices for multimorbidity such as the Charlson's Comorbidity Index (CCI) and HAS-BLED scores. RESULTS A total of 389 patients treated between January 1, 2001, and December 31, 2013, were identified; 169 underwent CDT and 220 underwent PAE. After IPTW, there were no significant differences in in-hospital mortality (18.2% vs 21.3%; odds ratio 1.07, 95% confidence interval [CI]: 0.70-1.62) or the incidence of safety outcomes between the CDT and PAE groups. The risks of all-cause mortality (30% vs 29.5%; hazard ratio 1.16, 95% CI: 0.89-1.53), recurrent PE (7.2% vs 8.7%; subdistribution hazard ratio [SHR] 0.68, 95% CI: 0.39-1.21) and new-onset pulmonary hypertension (SHR 0.25, 95% CI: 0.05-1.32) were also not significantly different between the CDT and PAE groups at 2 years of follow-up. Subgroup analysis indicated that PAE may be associated with a more favorable 2-year mortality in patients <65 years old, patients with CCI scores of <3, patients with HAS-BLED scores of 1 to 2, and patients without cardiogenic shock (all P for interaction <.05). CONCLUSIONS In patients with PE who required reperfusion therapy, CDT and PAE resulted in similar in-hospital and long-term all-cause mortality rates and long-term rates of recurrent PE. Bleeding risks were also comparable in the 2 groups.
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Affiliation(s)
- Donna Shu-Han Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | - Yu-Sheng Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Chiayi, Taiwan
| | - Jen-Kuang Lee
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Laboratory Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Jone Chen
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
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12
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Carrel T. Commentary: Surgical Embolectomy for Massive Pulmonary Embolism Revisited: A Contemporary Tribute to Trendelenburg Procedure. Semin Thorac Cardiovasc Surg 2021; 34:945-946. [PMID: 34274433 DOI: 10.1053/j.semtcvs.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 07/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zürich, Switzerland.
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13
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Lattouf OM, Laan D, Zapata D, Assaf EJ, Fallon J. Lessons learned on a new procedure: Nonsternotomy minimally invasive pulmonary embolectomy. J Card Surg 2021; 36:1258-1263. [PMID: 33538050 DOI: 10.1111/jocs.15357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/30/2020] [Accepted: 01/05/2021] [Indexed: 01/19/2023]
Abstract
The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through a standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. In a previous publication, we described a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This approach utilized a small 5-cm left upper parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. The first publication featured three patients that had a massive pulmonary embolus that was treated with minimally invasive pulmonary embolectomy, and the initial data was positive and suggested that this approach is safe and feasible. We now broaden our experience with another two patients who underwent this approach, and highlight a number of technical and management modifications that have been made to optimize the procedure. These lessons learned will ideally benefit future surgeons as this approach is more heavily implemented in practice.
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Affiliation(s)
- Omar M Lattouf
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Danuel Laan
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - David Zapata
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Edwyn J Assaf
- School of Medicine, American University of Beirut, Beirut, Lebanon
| | - John Fallon
- Department of Surgery, Division of Cardiothoracic Surgery, School of Medicine, Emory University, Atlanta, Georgia, USA
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14
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Fallon JM, Greenberg JW, Gupta L, Lattouf OM. Initial Experience with Non-Sternotomy Minimally Invasive Pulmonary Embolectomy with Thoracoscopic Assistance. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2021; 15:180-184. [PMID: 32352897 DOI: 10.1177/1556984520909803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
The endpoint in emergent management of acute massive pulmonary embolism (PE) has traditionally been with embolectomy through standard median sternotomy. This approach is limited in both exposure and concomitant functional morbidity associated with sternotomy. Herein we describe a novel minimally invasive, thoracoscopically assisted approach to pulmonary embolectomy. This utilizes a small 5-cm left parasternal thoracotomy and femoral cardiopulmonary bypass to conduct thoracoscopically assisted surgical pulmonary embolectomy. This novel minimally invasive approach has been developed and successfully utilized in 3 patients with massive PE at our institution. The assistance of the thoracoscope allowed for complete visualization and clot extraction of the main and segmental pulmonary arteries bilaterally. The use of a non-sternotomy approach sped both functional and pulmonary recovery times and decreased length of stay. These initial data suggest that non-sternotomy minimally invasive surgical pulmonary embolectomy with thoracoscopic assistance is a feasible and safe approach for acute massive PE that may result in enhanced recovery times and decreased hospital length of stay.
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Affiliation(s)
- John M Fallon
- 1371 Department of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
| | | | - Luvika Gupta
- 1421 Medical College of Georgia, Augusta, GA, USA
| | - Omar M Lattouf
- 1371 Department of Cardiothoracic Surgery, Emory University, Atlanta, GA, USA
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15
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QiMin W, LiangWan C, DaoZhong C, HanFan Q, ZhongYao H, XiaoFu D, XueShan H, Feng L, HuaBin C. Clinical outcomes of acute pulmonary embolectomy as the first-line treatment for massive and submassive pulmonary embolism: a single-centre study in China. J Cardiothorac Surg 2020; 15:321. [PMID: 33087152 PMCID: PMC7576708 DOI: 10.1186/s13019-020-01364-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background Acute pulmonary embolism (PE) is one of the most critical cardiovascular diseases. PE treatment ranges from anticoagulation, and systemic thrombolysis to surgical embolectomy and catheter embolectomy. Surgical pulmonary embolectmy (SPE) indications and outcomes are still controversial. Although there have been more favourable SPE reports over the past decades, SPE has not yet been considered broadly as an initial PE therapy and is still considered as a reserve or rescue treatment for acute massive PE when systemic thrombolysis fails. This study aimed to evaluate the early and midterm outcomes of SPE, which was a first-line therapy for acute central major PE in one Chinese single centre. Methods A retrospective review of patients who underwent SPE for acute PE was conducted.Patients with chronic thrombus or who underwent thromboendarterectomy were excluded. SPE risk factors for morbidity and mortality were reviewed, and echocardiographic examination were conducted for follow-up studies to access right ventricular function. Results Overall, 41 patients were included; 17 (41.5%) had submassive PE, and 24 (58.5%) had massive PE. Mean cardiopulmonary bypass time was 103.2 ± 48.9 min, and 10 patients (24.4%) underwent procedures without aortic cross-clamping. Ventilatory support time was 78 h (range, 40–336 h), intensive care unit stay was 7 days (range, 3–13 days), and hospital stay was 16 days (range, 12–23 days). Operative mortalities occurred in 3 massive PE patients, and no mortality occurred in submassive PE patients. The overall SPE mortality rate was 7.31% (3/41). If two systemic thrombolysis cases were excluded, SPE mortality was low (2.56%,1/39), evenlthough there were 2 cases of cardiac arrest preoperatively. Patients’ right ventricle function improved postoperatively in follow-ups.There were no deaths related to recurrent PE and chronic pulmonary hypertension in follow-ups, though 3 patients died of cerebral intracranial bleeding, gastric cancer,and brain cancer at 1 year, 3 years, and 8 years postoperatively, respectively. Conclusions SPE presented with a low mortality rate when rendered as a first-line treatment in selected massive and submassive acute PE patients. Favorable outcomes of right ventricle function were also observed in the follow-ups. SPE should play the same role as ST in algorithmic acute PE treatment.
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Affiliation(s)
- Wang QiMin
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China.
| | - Chen LiangWan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Chen DaoZhong
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Qiu HanFan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Huang ZhongYao
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Dai XiaoFu
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Huang XueShan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Lin Feng
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Chen HuaBin
- Fujian Medical University, Fuzhou, 350001, Fujian, China
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16
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Abstract
Acute pulmonary embolism (PE) is the third most common acute cardiovascular condition, and its prevalence increases over time. D-dimer has a very high negative predictive value, and if normal levels of D-dimer are detected, the diagnosis of PE is very unlikely. The final diagnosis should be confirmed by computed tomographic scan. However, echocardiography is the most available, bedside, low-cost, diagnostic procedure for patients with PE. Risk stratification is of utmost importance and is mainly based on hemodynamic status of the patient. Patients with PE and hemodynamic stability require further risk assessment, based on clinical symptoms, imaging, and circulating biomarkers.
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17
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Hong Son PD, Uoc NH, Lu PH, Hung DQ, Vo HL. Surgical pulmonary embolectomy in a multi-trauma patient: One-center experience in the resource-limited setting. SAGE Open Med Case Rep 2020; 8:2050313X20953753. [PMID: 32922799 PMCID: PMC7457691 DOI: 10.1177/2050313x20953753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/09/2020] [Indexed: 11/16/2022] Open
Abstract
Pulmonary embolism, a serious complication after trauma, may cause sudden death. We discuss an unusual case of 65-year-old woman who had traffic accident with liver injury and open fracture of both tibia and fibula on the right side. She was diagnosed with massive pulmonary embolism on the second day after accident and successfully underwent emergency surgical embolectomy from bilateral pulmonary arteries. There were no postoperative complications. The patient's good state of health was recorded after 13 months of surgery. Surgical pulmonary embolectomy for such a multi-trauma patient provides valuable experience not only for our institution but also for the countries having similar resource-limited conditions.
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Affiliation(s)
- Phung Duy Hong Son
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Huu Uoc
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Pham Huu Lu
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam
| | - Doan Quoc Hung
- Department of Cardiovascular and Thoracic Surgery, Viet Duc University Hospital, Hanoi, Vietnam.,Hanoi Medical University, Hanoi, Vietnam
| | - Hoang-Long Vo
- Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi, Vietnam.,Institute of Health Economics and Technology, Hanoi, Vietnam
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18
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Choi JH, O’Malley TJ, Maynes EJ, Weber MP, D’Antonio ND, Mellado M, West FM, Galanis T, Gonsalves CF, Marhefka GD, Awsare BK, Merli GJ, Tchantchaleishvili V. Surgical Pulmonary Embolectomy Outcomes for Acute Pulmonary Embolism. Ann Thorac Surg 2020; 110:1072-1080. [DOI: 10.1016/j.athoracsur.2020.01.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 12/10/2019] [Accepted: 01/30/2020] [Indexed: 12/18/2022]
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19
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Affiliation(s)
- Dale Shelton Deas
- Division of Cardiothoracic Surgery, Emory University, 550 Peachtree Street, MOT 6th floor, Atlanta, GA 30308, USA
| | - Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, 550 Peachtree Street, MOT 6th floor, Atlanta, GA 30308, USA.
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20
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Ayers B, Wood K, Cameron S, Marinescu M, Bjelic M, Barrus B, Gosev I. Surgical Pulmonary Embolectomy With No Systemic Anticoagulation for Patient With Recent Stroke. Ann Thorac Surg 2020; 110:e493-e495. [PMID: 32473129 DOI: 10.1016/j.athoracsur.2020.04.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 11/16/2022]
Abstract
We present the successful use of surgical embolectomy (SE) without systemic anticoagulation to treat a complicated case of pulmonary embolism. The patient presented with an embolic cerebrovascular accident and subsequently developed a massive pulmonary embolism. Because of the risk of hemorrhagic transformation, the decision was made to proceed with emergent SE on venoarterial extracorporeal membrane oxygenation support without anticoagulation. The surgery was performed without complication. The potential to perform SE without anticoagulation could potentially decrease the incidence of surgical bleeding and make SE a therapeutic option for patients with contraindications to anticoagulation. Further research is needed to substantiate the efficacy of this treatment strategy.
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Affiliation(s)
- Brian Ayers
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Katherine Wood
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Scott Cameron
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Mark Marinescu
- Division of Cardiology, Department of Medicine, University of Rochester Medical Center, Rochester, New York
| | - Milica Bjelic
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Bryan Barrus
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York.
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21
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Abstract
PURPOSE OF REVIEW To highlight updates on the use of extracorporeal membrane oxygenation (ECMO) and surgical embolectomy in the treatment of massive pulmonary embolism. RECENT FINDINGS Outcomes for surgical embolectomy for massive pulmonary embolism have improved in the recent past. More contemporary therapeutic options include catheter embolectomy, which although offer less invasive means of treating this condition, need further study. The use of ECMO as either a bridge or mainstay of treatment in patients with contraindications to fibrinolysis and surgical embolectomy, or have failed initial fibrinolysis, has increased, with data suggesting improved outcomes with earlier implementation in selected patients. SUMMARY Although surgical embolectomy continues to be the initial treatment of choice in massive pulmonary embolism with contraindications or failed fibrinolysis, the use of ECMO in these high-risk patients provides an important tool in managing this often fatal condition.
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22
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Martinez Licha CR, McCurdy CM, Maldonado SM, Lee LS. Current Management of Acute Pulmonary Embolism. Ann Thorac Cardiovasc Surg 2020; 26:65-71. [PMID: 31588070 PMCID: PMC7184035 DOI: 10.5761/atcs.ra.19-00158] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/16/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. While non-surgical approaches have supplanted surgery as primary treatment, surgical pulmonary embolectomy (SPE) remains a vital option for select patients. We review the current management of acute PE, with a focus on surgical therapy. METHODS A PubMed search was performed to identify literature regarding PE and treatment. Results were filtered to include the most comprehensive publications over the past decade. RESULTS PE is stratified based on presenting hemodynamic status or degree of mechanical pulmonary arterial occlusion. Although systemic or catheter-guided fibrinolysis is the preferred first-line treatment for the majority of cases, patients who are not candidates should be considered for SPE. Studies demonstrate no mortality benefit of thrombolysis over surgery. Systemic anticoagulation is a mainstay of treatment regardless of intervention approach. Following surgical embolectomy, direct oral anticoagulants (DOACs) have been shown to reduce recurrence of thromboembolism. CONCLUSIONS Acute PE presents with varying degrees of clinical stability. Patients should be evaluated in the context of various available treatment options including medical, catheter-based, and surgical interventions. SPE is a safe and appropriate treatment option for appropriate patients.
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Affiliation(s)
- Carlos R Martinez Licha
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chelsea M McCurdy
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarina Masso Maldonado
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
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23
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Martinez Licha CR, McCurdy CM, Maldonado SM, Lee LS. Current Management of Acute Pulmonary Embolism. ANNALS OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL JOURNAL OF THE ASSOCIATION OF THORACIC AND CARDIOVASCULAR SURGEONS OF ASIA 2020. [PMID: 31588070 DOI: 10.5761/atcs.ra.19-00158.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE Acute pulmonary embolism (PE) remains a significant cause of morbidity and requires prompt diagnosis and management. While non-surgical approaches have supplanted surgery as primary treatment, surgical pulmonary embolectomy (SPE) remains a vital option for select patients. We review the current management of acute PE, with a focus on surgical therapy. METHODS A PubMed search was performed to identify literature regarding PE and treatment. Results were filtered to include the most comprehensive publications over the past decade. RESULTS PE is stratified based on presenting hemodynamic status or degree of mechanical pulmonary arterial occlusion. Although systemic or catheter-guided fibrinolysis is the preferred first-line treatment for the majority of cases, patients who are not candidates should be considered for SPE. Studies demonstrate no mortality benefit of thrombolysis over surgery. Systemic anticoagulation is a mainstay of treatment regardless of intervention approach. Following surgical embolectomy, direct oral anticoagulants (DOACs) have been shown to reduce recurrence of thromboembolism. CONCLUSIONS Acute PE presents with varying degrees of clinical stability. Patients should be evaluated in the context of various available treatment options including medical, catheter-based, and surgical interventions. SPE is a safe and appropriate treatment option for appropriate patients.
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Affiliation(s)
- Carlos R Martinez Licha
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Chelsea M McCurdy
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarina Masso Maldonado
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana, USA
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24
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Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism as Bridge to Therapy. ASAIO J 2020; 66:146-152. [DOI: 10.1097/mat.0000000000000953] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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25
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Rivera-Lebron B, McDaniel M, Ahrar K, Alrifai A, Dudzinski DM, Fanola C, Blais D, Janicke D, Melamed R, Mohrien K, Rozycki E, Ross CB, Klein AJ, Rali P, Teman NR, Yarboro L, Ichinose E, Sharma AM, Bartos JA, Elder M, Keeling B, Palevsky H, Naydenov S, Sen P, Amoroso N, Rodriguez-Lopez JM, Davis GA, Rosovsky R, Rosenfield K, Kabrhel C, Horowitz J, Giri JS, Tapson V, Channick R. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin Appl Thromb Hemost 2019; 25:1076029619853037. [PMID: 31185730 PMCID: PMC6714903 DOI: 10.1177/1076029619853037] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.
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Affiliation(s)
| | | | - Kamran Ahrar
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abdulah Alrifai
- 4 University of Miami of Palm Beach Regional Campus/JFK Hospital, Atlantis, FL, USA
| | - David M Dudzinski
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Danielle Blais
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Roman Melamed
- 9 Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Rozycki
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Parth Rali
- 10 Temple University, Philadelphia, PA, USA
| | | | | | | | | | | | - Mahir Elder
- 14 Wayne State University, Detroit, MI, USA.,15 Michigan State University, East Lansing, MI, USA
| | | | | | | | | | | | | | | | - Rachel Rosovsky
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Rosenfield
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jay S Giri
- 16 University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Tapson
- 21 Cedars-Sinai Medical Center, Los Angeles, CA, USA
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26
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Schäfer B, Greim CA. [Acute perioperative right heart insufficiency : Diagnostics and treatment]. Anaesthesist 2019; 67:61-78. [PMID: 29270666 DOI: 10.1007/s00101-017-0394-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Acute right heart failure is often overlooked as a cause of cardiopulmonary insufficiency. The various pathologies underlying right heart failure at the level of afterload, preload and contractility, make rapid, targeted diagnostics necessary. In addition to clinical symptoms and laboratory chemical parameters, echocardiography in particular is relevant for making a diagnosis. Symptomatic treatment of the endangered patient is essential. The focus is on a reduction of right ventricular pressure and afterload, a correction of systemic hypotension and positive inotropic support of the right ventricle. Mechanical organ replacement and support procedures are increasingly being used in the case of persistent right heart failure and expand the possibilities for treatment. Decisive for the prognosis is a causal treatment adapted to the underlying triggering disease.
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Affiliation(s)
- B Schäfer
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Deutschland
| | - C-A Greim
- Klinik für Anästhesiologie, Intensiv- und Notfallmedizin, Klinikum Fulda, Pacelliallee 4, 36043, Fulda, Deutschland.
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27
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Tran QK, O'Connor J, Vesselinov R, Haase D, Duncan R, Aitken A, Rea JH, Jones K, Dinardo T, Scalea T, Menaker J, Rubinson L. The Critical Care Resuscitation Unit Transfers More Patients From Emergency Departments Faster and Is Associated With Improved Outcomes. J Emerg Med 2019; 58:280-289. [PMID: 31761462 DOI: 10.1016/j.jemermed.2019.09.041] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Transfer delays of critically ill patients from other hospitals' emergency departments (EDs) to an appropriate referral hospital's intensive care unit (ICU) are associated with poor outcomes. OBJECTIVES We hypothesized that an innovative Critical Care Resuscitation Unit (CCRU) would be associated with improved outcomes by reducing transfer times to a quaternary care center and times to interventions for ED patients with critical illnesses. METHODS This pre-post analysis compared 3 groups of patients: a CCRU group (patients transferred to the CCRU during its first year [July 2013 to June 2014]), a 2011-Control group (patients transferred to any ICU between July 2011 and June 2012), and a 2013-Control group (patients transferred to other ICUs between July 2013 and June 2014). The primary outcome was time from transfer request to ICU arrival. Secondary outcomes were the interval between ICU arrival to the operating room and in-hospital mortality. RESULTS We analyzed 1565 patients (644 in the CCRU, 574 in the 2011-Control, and 347 in 2013-Control groups). The median time from transfer request to ICU arrival for CCRU patients was 108 min (interquartile range [IQR] 74-166 min) compared with 158 min (IQR 111-252 min) for the 2011-Control and 185 min (IQR 122-283 min) for the 2013-Control groups (p < 0.01). The median arrival-to-urgent operation for the CCRU group was 220 min (IQR 120-429 min) versus 439 min (IQR 290-645 min) and 356 min (IQR 268-575 min; p < 0.026) for the 2011-Control and 2013-Control groups, respectively. After adjustment with clinical factors, transfer to the CCRU was associated with lower mortality (odds ratio 0.64 [95% confidence interval 0.44-0.93], p = 0.019) in multivariable logistic regression. CONCLUSION The CCRU, which decreased time from outside ED's transfer request to referral ICU arrival, was associated with lower mortality likelihood. Resuscitation units analogous to the CCRU, which transfer resource-intensive patients from EDs faster, may improve patient outcomes.
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Affiliation(s)
- Quincy K Tran
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - James O'Connor
- The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Roumen Vesselinov
- Department of Epidemiology and Public Health, University of Maryland at Baltimore, Baltimore, Maryland
| | - Daniel Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rebecca Duncan
- The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ashley Aitken
- University of Maryland Medical Center, Baltimore, Maryland
| | - Jeffrey H Rea
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Thomas Scalea
- The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Jay Menaker
- The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland; Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Lewis Rubinson
- The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland; Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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[What are the indications and options for vascular reperfusion in the acute phase of pulmonary embolism?]. Rev Mal Respir 2019; 38 Suppl 1:e53-e58. [PMID: 31585780 DOI: 10.1016/j.rmr.2019.05.004] [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]
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Abstract
Pulmonary embolism (PE) presents a spectrum of hemodynamic consequences, ranging from being asymptomatic to a life-threatening medical emergency. Management of submassive and massive PE often involves clinicians from multiple specialties, which can potentially delay the development of a unified treatment plan. In addition, patients with submassive PE can deteriorate after their presentation and require escalation of care. Underlying comorbidities such as chronic obstructive pulmonary disease, cancer, congestive heart failure, and interstitial lung disease can impact the patient's hemodynamic ability to tolerate submassive PE. In this review, we address the definitions, risk stratification (clinical, laboratory, and imaging), management approaches, and long-term outcomes of submassive PE. We also discuss the role of the PE response team in management of patients with PE.
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Affiliation(s)
- Parth M Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
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30
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LeVarge BL, Wright CD, Rodriguez-Lopez JM. Surgical Management of Acute and Chronic Pulmonary Embolism. Clin Chest Med 2019; 39:659-667. [PMID: 30122189 DOI: 10.1016/j.ccm.2018.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Surgical pulmonary embolectomy and pulmonary thromboendarterectomy are well-established treatment strategies for patients with acute and chronic pulmonary embolism, respectively. For both procedures, techniques and outcomes have evolved considerably over the past decades. Patients with massive and submassive acute pulmonary embolism are at risk for rapid decline owing to right ventricular failure and shock. When thrombus is proximal, embolectomy can rapidly restore cardiac function. Chronic thromboembolic pulmonary hypertension is a more complex disease that requires skilled, careful dissection of the arterial wall, including vascular intima. When successful, surgery leads to clinical cure of the associated pulmonary hypertension, with excellent long-term outcomes.
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Affiliation(s)
- Barbara L LeVarge
- Division of Pulmonary Diseases and Critical Care Medicine, Department of Medicine, University of North Carolina, 130 Mason Farm Road CB 7020, Chapel Hill, NC 27599, USA.
| | - Cameron D Wright
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Josanna M Rodriguez-Lopez
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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31
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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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32
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[New aspects of thrombolysis and thrombectomy in pulmonary embolism]. Herz 2019; 44:324-329. [PMID: 30941473 DOI: 10.1007/s00059-019-4801-z] [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: 10/27/2022]
Abstract
Pulmonary embolism is a potentially life-threatening disease, which can present with varying severity. Based on an emergency risk stratification, the initial treatment strategy should be chosen without delay. While patients with a low mortality risk can be treated in an outpatient setting, patients at high risk should proceed to immediate recanalization by thrombolysis or thrombectomy. Systemic thrombolysis is the first line therapy in the absence of contraindications. The dosing (low versus full dose) and application (systemic versus local via a catheter) of alteplase, the most frequently used agent, is the subject of a number of current studies with the goal to reduce the risk of bleeding. In the case of contraindications for systemic thrombolysis surgical or alternatively, interventional thrombectomy should be performed. This article discusses these procedures in the light of the currently available literature.
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Bhamani A, Pepke-Zaba J, Sheares K. Lifting the fog in intermediate-risk (submassive) PE: full dose, low dose, or no thrombolysis? F1000Res 2019; 8:F1000 Faculty Rev-330. [PMID: 30984375 PMCID: PMC6436190 DOI: 10.12688/f1000research.17861.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2019] [Indexed: 11/23/2022] Open
Abstract
Acute pulmonary embolism (PE) is a disease frequently encountered in clinical practice. While the management of haemodynamically stable, low risk patients with acute PE is well established, managing intermediate disease often presents a therapeutic dilemma. In this review, we discuss the various therapeutic options available in this patient group. This includes thrombolysis, surgical embolectomy and catheter directed techniques. We have also explored the role of specialist PE response teams in the management of such patients. .
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Affiliation(s)
- Amyn Bhamani
- Department of Respiratory Medicine, Basildon and Thurrock University Hospital, Basildon, Essex, SS16 5NL
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, CB23 3RE
| | - Karen Sheares
- Pulmonary Vascular Diseases Unit, Royal Papworth Hospital, Cambridge, CB23 3RE
- Department of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ
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34
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Ius F, Hoeper MM, Fegbeutel C, Kühn C, Olsson K, Koigeldiyev N, Tudorache I, Warnecke G, Optenhöfel J, Puntigam JO, Schäfer A, Meyer BC, Hinrichs JB, Bauersachs J, Haverich A, Cebotari S. Extracorporeal membrane oxygenation and surgical embolectomy for high-risk pulmonary embolism. Eur Respir J 2019; 53:13993003.01773-2018. [DOI: 10.1183/13993003.01773-2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 01/11/2019] [Indexed: 11/05/2022]
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35
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Alirezaei T, Aval ZA. Rescue thrombolysis partial failure in massive PE complicated with in-transit thrombus. Int Med Case Rep J 2019; 12:9-14. [PMID: 30666168 PMCID: PMC6330970 DOI: 10.2147/imcrj.s189944] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A 58-year-old man who presented with syncope, dyspnea, and hemodynamic compromise was found to have large free-floating right atrial thrombuses on echocardiogram. Decision was made to transfer the patient for emergent atriotomy. Cardiothoracic surgeons declared the patient as inoperable and recommended to use a lytic agent. Alteplase was administered with subsequent near-complete resolution of symptoms and near-normalization of echocardio-graphic parameters. The post-thrombolytic course was complicated by saddle pulmonary emboli requiring embolectomy. Catheter embolectomy was not available and cardiothoracic surgeon in other center considered the patient to be very high risk for transferring between hospitals and surgical intervention. Ultimately, the critical decision was made, despite the patient having been administered thrombolytic therapy within the previous 48 hours. Alteplase was given, but was not effective and the patient required surgical intervention. Surgical embolectomy was done successfully in another hospital and the patient was discharged with warfarin.
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Affiliation(s)
- Toktam Alirezaei
- Cardiology Department of Shohaday-e-Tajrish Hospital, Shahid Behesti University of Medical Science, Tehran, Iran,
| | - Zahra Ansari Aval
- Cardiovascular Research Center, Shahid Behesti University of Medical Science, Tehran, Iran
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36
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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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37
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Minakawa M, Fukuda I, Miyata H, Motomura N, Takamoto S, Taniguchi S, Daitoku K, Kondo N. Outcomes of Pulmonary Embolectomy for Acute Pulmonary Embolism. Circ J 2018; 82:2184-2190. [DOI: 10.1253/circj.cj-18-0371] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masahito Minakawa
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Ikuo Fukuda
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Hiroaki Miyata
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Noboru Motomura
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Shinichi Takamoto
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Satoshi Taniguchi
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Kazuyuki Daitoku
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
| | - Norihiro Kondo
- Department of Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine
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38
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Fernandes CJCDS, Jardim CVP, Alves JL, Oleas FAG, Morinaga LTK, de Souza R. Reperfusion in acute pulmonary thromboembolism. J Bras Pneumol 2018; 44:0. [PMID: 29898007 PMCID: PMC6188696 DOI: 10.1590/s1806-37562017000000204] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 01/19/2018] [Indexed: 01/03/2023] Open
Abstract
Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.
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Affiliation(s)
- Caio Julio Cesar dos Santos Fernandes
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
- . Instituto do Câncer, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Carlos Vianna Poyares Jardim
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - José Leonidas Alves
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
- . Instituto do Câncer, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Francisca Alexandra Gavilanes Oleas
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Luciana Tamie Kato Morinaga
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rogério de Souza
- . Unidade de Circulação Pulmonar, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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39
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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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Pasrija C, Kronfli A, Rouse M, Raithel M, Bittle GJ, Pousatis S, Ghoreishi M, Gammie JS, Griffith BP, Sanchez PG, Kon ZN. Outcomes after surgical pulmonary embolectomy for acute submassive and massive pulmonary embolism: A single-center experience. J Thorac Cardiovasc Surg 2018; 155:1095-1106.e2. [DOI: 10.1016/j.jtcvs.2017.10.139] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/18/2017] [Accepted: 10/08/2017] [Indexed: 02/06/2023]
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42
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Hirji SA, Kaneko T, Aranki S. Surgical embolectomy for pulmonary embolism: About time for a randomized clinical trial? J Thorac Cardiovasc Surg 2018; 155:1080-1081. [DOI: 10.1016/j.jtcvs.2017.10.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 10/07/2017] [Indexed: 11/25/2022]
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43
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Lee T, Itagaki S, Chiang YP, Egorova NN, Adams DH, Chikwe J. Survival and recurrence after acute pulmonary embolism treated with pulmonary embolectomy or thrombolysis in New York State, 1999 to 2013. J Thorac Cardiovasc Surg 2018; 155:1084-1090.e12. [PMID: 28942971 DOI: 10.1016/j.jtcvs.2017.07.074] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 07/04/2017] [Accepted: 07/29/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Timothy Lee
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Shinobu Itagaki
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Yuting P Chiang
- Department of Surgery, Columbia University Medical Center, New York Presbyterian Hospital, New York, NY
| | - Natalia N Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David H Adams
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Joanna Chikwe
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, NY; Division of Cardiothoracic Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY.
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44
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Baciewicz FA. Play it again…Dr Gibbon. J Thorac Cardiovasc Surg 2018; 155:1082-1083. [PMID: 29331181 DOI: 10.1016/j.jtcvs.2017.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 11/13/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Frank A Baciewicz
- Division of Cardiothoracic Surgery, Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich.
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45
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Outcome of surgical embolectomy in patients with massive pulmonary embolism with and without cardiopulmonary resuscitation. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2017; 14:241-244. [PMID: 29354176 PMCID: PMC5767774 DOI: 10.5114/kitp.2017.72228] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Accepted: 11/12/2017] [Indexed: 11/17/2022]
Abstract
Introduction Pulmonary embolism is a challenging critical cardiovascular disease with high morbidity and mortality. Surgical embolectomy has favorable results in patients with massive pulmonary embolism. Aim To study the outcome of embolectomy in patients with massive pulmonary embolism. Material and methods In this single-center, retrospective study, 36 patients including 14 male and 22 female patients with a mean age of 50.80 ±18.89 years with acute pulmonary embolism who underwent surgical pulmonary embolectomy from January 2011 to January 2016 were included. The medical records of all patients were reviewed for demographic and preoperative data and postoperative outcomes. Results Common risk factors for acute PE were major surgery within 3 months and deep vein thrombosis. The most common presenting symptoms of patients were dyspnea, followed by chest pain and syncope. Mean duration of hospitalization was 14.76 ±8.69 days and mean operation duration was 4.47 ±1.54 h. Mean time from admission to embolectomy was 6.58 ±1.13 h. Ten (27.8%) patients died during the operation including 3 cases with cardiopulmonary resuscitation prior to surgery and 2 cases with severe cardiogenic shock. Patients who survived were followed for 6 months. The mortality rate during follow-up was 15.4%; all 4 patients died during follow-up period due to metastatic cancer. No pulmonary embolism recurrance were seen. Conclusions Although surgical embolectomy mostly was done for high risk patients, it had good in-hospital and excellent mid-term outcomes.
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Gerardin B, Glorion M, Rodriguez A, Garcia C, Stephan F, Fabre D, Mercier O, Brenot P, Fadel E. [Massive pulmonary embolism. When medical treatment is not enough]. Ann Cardiol Angeiol (Paris) 2017; 66:453-459. [PMID: 29122207 DOI: 10.1016/j.ancard.2017.10.014] [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: 10/18/2022]
Abstract
Emergency bedside veno-arterious ECMO implantation can be the only saving gesture in the suspicion of acute massive pulmonary embolism leading to haemodynamic failure, even before CT-scan imaging. Once the massive pulmonary embolism is confirmed it is possible to undergo surgical or percutaneous pulmonary thrombectomy, when thrombolytic therapy is contraindicated.
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Affiliation(s)
- B Gerardin
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France.
| | - M Glorion
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - A Rodriguez
- Hôpital du Kremlin-Bicêtre, 78, avenue du Général Leclerc, 94270 Le Kremlin-Bicêtre, France
| | - C Garcia
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - F Stephan
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - D Fabre
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - O Mercier
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - P Brenot
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
| | - E Fadel
- Hôpital Marie-Lannelongue, 133, avenue de la résistance, 92350 Le Plessis Robinson, France
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Lehnert P, Møller CH, Mortensen J, Kjaergaard J, Olsen PS, Carlsen J. Surgical embolectomy compared to thrombolysis in acute pulmonary embolism: morbidity and mortality. Eur J Cardiothorac Surg 2017; 51:354-361. [PMID: 28186234 DOI: 10.1093/ejcts/ezw297] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/03/2016] [Accepted: 07/22/2016] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES The aim of this study was to investigate the long-term outcome after acute high- and intermediate-risk pulmonary embolism (PE) treated with surgical embolectomy or thrombolysis. METHODS Prospective follow-up including assessment of 30-day and 5-year mortality. Clinical evaluation including ventilation/perfusion scintigraphy by single-photon emission computed tomography in combination with X-ray computed tomography, measurement of pulmonary diffusion impairment, spirometry and echocardiography. RESULTS A total of 136 patients (64 with high-risk and 72 with intermediate-risk PE) were included, 80 participated in the clinical follow-up, 16 were alive but declined follow-up and 40 were deceased. For high-risk PE patients the median time to clinical follow-up was 31 months [8–133]. No significant difference was observed in 30-day (Plog-rank = 0.16) or 5-year (Plog-rank = 0.53) mortality between patients treated with surgical embolectomy or thrombolysis. Ventilation/perfusion mismatch identified residual emboli in 4 patients (31%) treated with surgical embolectomy compared to 16 (76%) treated with thrombolysis (P = 0.009). Pulmonary diffusion impairment was identified in 4 patients (31%) treated with surgical embolectomy in comparison to 15 (71%) treated with thrombolysis (P = 0.02). In intermediate-risk PE patients, no significant difference in mortality (Plog-rank = 0.51 and 0.86), diffusion impairment or ventilation/perfusion mismatch was found between patients treated with surgical embolectomy or thrombolysis. CONCLUSIONS Surgical embolectomy for acute high-risk PE has similar mortality, but better outcome on pulmonary end-points when compared to thrombolysis. Patients with high-risk PE could benefit from being referred to a centre with both specialized cardiology and cardiothoracic surgery for interdisciplinary evaluation of optimal treatment strategy.
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Affiliation(s)
- Per Lehnert
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian H Møller
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology, Nuclear Medicine and PET, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Peter Skov Olsen
- Department of Cardiothoracic Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørn Carlsen
- Department of Cardiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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48
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Fukuda I, Daitoku K. Surgical Embolectomy for Acute Pulmonary Thromboembolism. Ann Vasc Dis 2017; 10:107-114. [PMID: 29034035 PMCID: PMC5579785 DOI: 10.3400/avd.ra.17-00038] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 04/19/2017] [Indexed: 12/18/2022] Open
Abstract
Acute pulmonary thromboembolism is a catastrophic event, especially for hospitalized patients. The prognosis of pulmonary thromboembolism depends on the degree of pulmonary arterial occlusion. The mortality of massive pulmonary embolism is reportedly as high as 25% without cardiopulmonary arrest and 65% with cardiopulmonary arrest. In patients with unstable hemodynamics due to pulmonary thromboembolism, surgical pulmonary embolectomy is indicated for patients with a contraindication to thrombolysis, failed catheter therapy, or failed thrombolysis. Thrombolytic therapy adds an additional burden on patients who are at risk of potential hemorrhagic complications. It is also indicated if patients are already on a veno-arterial extra-corporate membrane oxygenator for circulatory collapse or cardiopulmonary arrest. The outcome for patients who require cardiopulmonary resuscitation for longer than 30 minutes is poor. Therefore, early triage for massive and sub-massive pulmonary embolism is crucial. A team approach including a cardiovascular surgeon may be effective to save critically ill patients. Prompt removal of emboli reduces the right ventricular load with quick recovery of cardiopulmonary function in the early postoperative period. A recent series reported excellent results, with in-hospital mortality of less than 10%. Surgical pulmonary embolectomy is an effective, safe, and easy procedure to save critical patients due to pulmonary thromboembolism.
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Affiliation(s)
- Ikuo Fukuda
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
| | - Kazuyuki Daitoku
- Thoracic and Cardiovascular Surgery, Hirosaki University Graduate School of Medicine, Hirosaki, Aomori, Japan
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49
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Saleh J, El-Othmani MM, Saleh KJ. Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery. Orthop Clin North Am 2017; 48:127-135. [PMID: 28336037 DOI: 10.1016/j.ocl.2016.12.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.
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Affiliation(s)
- Jasmine Saleh
- Department of Research Institute, National Institute of Health, 9000 Rockville Pike Street, Bethesda, MD 20892, USA
| | - Mouhanad M El-Othmani
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA
| | - Khaled J Saleh
- Department of Orthopaedics and Sports Medicine, Detroit Medical Center, University Health Center (UHC), 4201 Saint Antoine Street, 9B, Detroit, MI 48201-2153, USA.
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50
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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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