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Forter-Chee-A-Tow N, Smith A. Role of surgical embolectomy in the management of acute massive and submassive pulmonary embolism in the setting of a small island developing state. J Surg Case Rep 2023; 2023:rjad468. [PMID: 37593185 PMCID: PMC10432080 DOI: 10.1093/jscr/rjad468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/30/2023] [Indexed: 08/19/2023] Open
Abstract
Acute pulmonary embolism (PE) remains a life-threatening condition despite advances in diagnostic and therapeutic modalities. Treatment modalities include systemic thrombolysis, catheter-based therapies and surgical embolectomy. This case report describes the first recorded surgical embolectomy for acute PE in Barbados, a small island developing state.
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Affiliation(s)
| | - Alan Smith
- University of the West Indies at Cave Hill, Faculty of Medical Sciences, The Queen Elizabeth Hospital, Bridgetown, St Michael, Barbados
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2
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Haft JW, Yost G. Open Surgical Treatment of Acute and Chronic Pulmonary Embolism. Interv Cardiol Clin 2023; 12:339-347. [PMID: 37290838 DOI: 10.1016/j.iccl.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Acute pulmonary embolism (PE) is a common cause of death and morbidity in the United States and the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH), a possible sequela of PE, has increased during the past decade. The mainstay treatment of CTEPH is open pulmonary endarterectomy, a procedure performed under hypothermic circulatory arrest, which entails endarterectomy of the branch, segmental and subsegmental pulmonary arteries. Acute PE may be similarly be treated with an open embolectomy in certain select circumstances.
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Affiliation(s)
- Jonathan W Haft
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA.
| | - Gardner Yost
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA
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3
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Kim TS. Surgical Embolectomy of Acute Pulmonary Embolism. Phlebology 2022. [DOI: 10.37923/phle.2022.20.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tae Sik Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, Korea
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4
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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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5
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Osho AA, Dudzinski DM. Interventional Therapies for Acute Pulmonary Embolism. Surg Clin North Am 2022; 102:429-447. [DOI: 10.1016/j.suc.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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6
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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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7
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Bhalla A, Attaran R. Mechanical Circulatory Support to Treat Pulmonary Embolism: Venoarterial Extracorporeal Membrane Oxygenation and Right Ventricular Assist Devices. Tex Heart Inst J 2020; 47:202-206. [PMID: 32997787 DOI: 10.14503/thij-19-7025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Mechanical circulatory support may help patients with massive pulmonary embolism who are not candidates for systemic thrombolysis, pulmonary embolectomy, or catheter-directed therapy, or in whom these established interventions have failed. Little published literature covers this topic, which led us to compare outcomes of patients whose massive pulmonary embolism was managed with the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) or a right ventricular assist device (RVAD). We searched the medical literature from January 1990 through September 2018 for reports of adults hospitalized for massive or high-risk pulmonary embolism complicated by hemodynamic instability, and who underwent VA-ECMO therapy or RVAD placement. Primary outcomes included weaning from mechanical circulatory support and discharge from the hospital. We found 16 reports that included 181 patients (164 VA-ECMO and 17 RVAD). All RVAD recipients were successfully weaned from support, as were 122 (74%) of the VA-ECMO patients. Sixteen (94%) of the RVAD patients were discharged from the hospital, as were 120 (73%) of the VA-ECMO patients. Of note, the 8 RVAD patients who had an Impella RP System were all weaned and discharged. For patients with massive pulmonary embolism who are not candidates for conventional interventions or whose conditions are refractory, mechanical circulatory support in the form of RVAD placement or ECMO may be considered. Larger comparative studies are needed.
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Affiliation(s)
- Aneil Bhalla
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut 06519
| | - Robert Attaran
- Section of Cardiovascular Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut 06519
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8
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Tan CW, Balla S, Ghanta RK, Sharma AM, Chatterjee S. Contemporary Management of Acute Pulmonary Embolism. Semin Thorac Cardiovasc Surg 2020; 32:396-403. [PMID: 32353408 DOI: 10.1053/j.semtcvs.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/13/2020] [Indexed: 11/11/2022]
Abstract
Multiple treatment options beyond anticoagulation exist for massive and submassive pulmonary embolism to reduce mortality. For some patients, systemic thrombolytics and catheter-directed thrombolysis are appropriate interventions. For others, surgical pulmonary embolectomy can be life-saving. Extracorporeal life support and right ventricular assist devices can provide hemodynamic support in challenging cases. We propose a management algorithm for the treatment of massive and submassive pulmonary embolism, in conjunction with a multidisciplinary pulmonary embolism response team, to guide clinicians in individualizing treatment for patients in a timely manner.
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Affiliation(s)
- Corinne W Tan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sujana Balla
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Aditya M Sharma
- Department of Medicine, University of Virginia, Health Sciences Center, Charlottesville, Virginia
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
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9
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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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10
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Khorev NG, Beller AV, Borovikov ÉV, Kon'kova VO, Shoĭkhet IN. [Comparative efficacy of various thrombolytic agents in treatment of pulmonary embolism]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2019; 25:23-28. [PMID: 31503244 DOI: 10.33529/angi02019316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The authors carried out a retrospective analysis of clinical efficacy of streptokinase and alteplase (actilyse®) in patients presenting with high- and intermediate-to-high risk pulmonary artery thromboembolism (PATE) who were discharged from hospital after appropriate treatment performed. Of the total number of the treated patients, we formed 2 groups comprising 20 patients each, receiving alteplase (group 1) and streptokinase (group 2). The patients were comparable by the main clinical characteristics, predisposing factors, severity of pulmonary artery thromboembolism (PATE) and duration of treatment. Efficacy of thrombolytic therapy assessed clinically and instrumentally did not differ. However, by the stratified risk and frequency of PATE relapses, the condition of patients receiving alteplase turned out to be more severe. Based on the obtained results, a conclusion was made that actilyse is a drug of choice for treatment of patients with PATE.
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Affiliation(s)
- N G Khorev
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia; Departmental Clinical Hospital at the Barnaul Station of the Open Joint Stock Company 'Russian Railways', Barnaul, Russia
| | - A V Beller
- Departmental Clinical Hospital at the Barnaul Station of the Open Joint Stock Company 'Russian Railways', Barnaul, Russia
| | | | - V O Kon'kova
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia; Municipal Hospital #5, Barnaul, Russia
| | - Ia N Shoĭkhet
- Altai State Medical University of the RF Ministry of Public Health, Barnaul, Russia
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Moore C, McNamara K, Liu R. Challenges and Changes to the Management of Pulmonary Embolism in the Emergency Department. Clin Chest Med 2018; 39:539-547. [DOI: 10.1016/j.ccm.2018.04.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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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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13
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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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14
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Kongkatong M, Swartzentruber D, Singletary E. A Middle-aged Female with Dyspnea. Ann Emerg Med 2017; 69:396-415. [PMID: 28335912 DOI: 10.1016/j.annemergmed.2016.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Matthew Kongkatong
- Department of Emergency Medicine, University of Virginia, Charlottesville, VA
| | | | - Eunice Singletary
- Department of Emergency Medicine, University of Virginia, Charlottesville, VA
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15
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Hui DS, Fleischman F, McFadden PM. Thromboembolism-in-Transit and Patent Foramen Ovale: Should Screening Echocardiogram Be Routine for Thromboembolic Disease? Ochsner J 2016; 16:321-323. [PMID: 27660585 PMCID: PMC5024818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Thromboembolism-in-transit straddling a patent foramen ovale (PFO) is a rare condition that requires urgent surgical intervention to prevent arterial emboli. CASE REPORT We present the case of a 42-year-old female who presented with a symptomatic pulmonary embolism. Echocardiography identified a PFO, with a bridging thrombus-in-transit and evidence of right ventricular strain. Urgent surgery was performed because of the risk of systemic embolism. A large thrombus was identified during biatrial exploration. Pulmonary embolectomy and primary PFO closure were performed. CONCLUSION Because of the 20%-30% incidence of PFOs in the general population, we suggest that echocardiography should be considered for routine surveillance in thromboembolism because of the risk of systemic sequelae.
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Affiliation(s)
- Dawn S. Hui
- Center for Comprehensive Cardiovascular Care, Saint Louis University, St. Louis, MO
| | - Fernando Fleischman
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - P. Michael McFadden
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
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16
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Saxena P, Smail H, McGiffin DC. Surgical Techniques of Pulmonary Embolectomy for Acute Pulmonary Embolism. ACTA ACUST UNITED AC 2016. [DOI: 10.1053/j.optechstcvs.2017.02.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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17
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King C, May CW, Williams J, Shlobin OA. Management of right heart failure in the critically ill. Crit Care Clin 2015; 30:475-98. [PMID: 24996606 DOI: 10.1016/j.ccc.2014.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Right ventricular failure complicates several commonly encountered conditions in the intensive care unit. Right ventricular dilation and paradoxic movement of the interventricular septum on echocardiography establishes the diagnosis. Right heart catheterization is useful in establishing the specific cause and aids clinicians in management. Principles of treatment focus on reversal of the underlying cause, optimization of right ventricular preload and contractility, and reduction of right ventricular afterload. Mechanical support with right ventricular assist device or veno-arterial extracorporeal membrane oxygenation can be used in select patients who fail to improve with optimal medical therapy.
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Affiliation(s)
- Christopher King
- Medical Critical Care Service, Inova Fairfax Hospital, 618 South Royal Street, Alexandria, VA 22314, USA.
| | - Christopher W May
- Advanced Heart Failure and Cardiac Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Jeffrey Williams
- Medical Critical Care Service, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Oksana A Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, 3300 Gallows Road, Falls Church, VA 22042, USA
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18
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Neely RC, Byrne JG, Gosev I, Cohn LH, Javed Q, Rawn JD, Goldhaber SZ, Piazza G, Aranki SF, Shekar PS, Leacche M. Surgical Embolectomy for Acute Massive and Submassive Pulmonary Embolism in a Series of 115 Patients. Ann Thorac Surg 2015; 100:1245-51; discussion 1251-2. [PMID: 26165484 DOI: 10.1016/j.athoracsur.2015.03.111] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 03/20/2015] [Accepted: 03/25/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Pulmonary embolectomy is often indicated for central pulmonary embolism (PE) with hemodynamic instability, but remains controversial for hemodynamically stable patients with signs of right ventricular dysfunction. Because thrombolytic therapy is often contraindicated postoperatively, we reviewed risk factors and outcomes of pulmonary embolectomy for stable and unstable central PE, particularly in the early postoperative period. METHODS Between October 1999 and September 2013, 115 patients underwent pulmonary embolectomy for central, hemodynamically unstable PE (49 of 115, 43%) or hemodynamically stable PE (56 of 115, 49%). Ten operations for alternate indications (right atrial mass, endocarditis) were excluded for comparison analysis, leaving 105 patients. RESULTS Mean age was 59 ± 13 years; 46 of 105 patients (44%) had recent surgery (within 5 weeks): orthopedic (12 of 46, 25%), neurosurgery (11 of 46, 24%), or general surgery (10 of 46, 22%). Preoperative demographics did not differ between groups, except for the frequency of cardiopulmonary resuscitation among unstable patients (11 of 49, 22%) versus stable patients (0 of 56, 0%; p < 0.001). Operative mortality for the combined groups was 6.6% (7 of 105): unstable 10.2% (5 of 49) versus stable 3.6% (2 of 56; p = 0.247). Of 11 patients requiring preoperative cardiopulmonary resuscitation, 4 died. Six-month, 1-year, and 3-year survival rates were, respectively, 75%, 68.4%, and 65.8% for unstable PE, and 92.6%, 86.7%, and 80.4% for stable PE (p = 0.018). CONCLUSIONS This large series of pulmonary embolectomies demonstrates excellent early and late survival rates for patients with stable PE and unstable PE. These findings confirm pulmonary embolectomy as a beneficial therapeutic option for central PE, especially during the postoperative period when thrombolytic therapy is often contraindicated.
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Affiliation(s)
- Robert C Neely
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - John G Byrne
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Igor Gosev
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Lawrence H Cohn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Quratulain Javed
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James D Rawn
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Samuel Z Goldhaber
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Gregory Piazza
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sary F Aranki
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Prem S Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marzia Leacche
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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19
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Spagnolo S, Barbato L, Grasso MA, Tesler UF. Retrograde pulmonary perfusion as an adjunct to standard pulmonary embolectomy for acute pulmonary embolism. Multimed Man Cardiothorac Surg 2014; 2014:mmu019. [PMID: 25298365 DOI: 10.1093/mmcts/mmu019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Mortality rates for pulmonary embolectomy in patients with acute massive pulmonary embolism have decreased in recent years. However, it still ranges from 30 to 45% when surgery is performed on critically ill patients, and the mortality rates reach 60% in patients who have experienced a cardiac arrest before the procedure. The causes of death in these patients are generally attributed to right heart failure due to persistent pulmonary hypertension, intractable pulmonary oedema, and massive parenchymal and intrabronchial haemorrhage. Clinical and experimental findings indicate that venous air embolism causes severe or even lethal damage to the pulmonary microvasculature and the lung parenchyma consequent to the release of endothelium-derived cytokines. These findings are similar to those observed when severely compromised patients undergo pulmonary embolectomy for air entrapped in the pulmonary artery during embolectomy, which may lead to fatal outcomes. Retrograde pulmonary perfusion (RPP), besides enabling the removal of residual thrombotic material from the peripheral branches of the pulmonary artery, fills the pulmonary artery with blood and prevents pulmonary air embolism. We believe that the use of RPP as an adjunct to conventional pulmonary embolectomy decreases the morbidity and mortality rates associated with pulmonary embolectomy in critically ill patients.
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Affiliation(s)
| | - Luciano Barbato
- Department of Cardiac Surgery, Policlinico di Monza, Monza, Italy
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20
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Chon MK, Park YH, Choi JH, Lee SH, Kim JS, Kim J, Kim JH, Chun KJ. Thrombolytic therapy complemented by ECMO: successful treatment for a case of massive pulmonary thromboembolism with hemodynamic collapse. J Korean Med Sci 2014; 29:735-8. [PMID: 24851033 PMCID: PMC4024947 DOI: 10.3346/jkms.2014.29.5.735] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2013] [Accepted: 10/17/2013] [Indexed: 12/16/2022] Open
Abstract
Pulmonary thromboembolism (PTE) is a common clinical condition related to significant mortality. Furthermore, patients with PTE presenting with right heart thrombus show higher mortality due to rapid hemodynamic deterioration. But the optimal treatment of massive PTE is controversial although various methods have been developed and improved. Here, we presented a case of 56-yr-old woman with massive PTE showing hemodynamic collapse, who was successfully treated with extracorporeal membrane oxygenation (ECMO) adjunct to thrombolytic therapy even without thrombectomy. ECMO was useful for resuscitation and stabilization of the cardiopulmonary function. In conclusion, thrombolytic therapy complemented by ECMO may be an effective treatment option for acute massive PTE with hemodynamic instability.
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Affiliation(s)
- Min Ku Chon
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Yong Hyun Park
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jin Hee Choi
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Hyun Lee
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jeong Su Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jun Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - June Hong Kim
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Kook Jin Chun
- Division of Cardiology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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Worku B, Gulkarov I, Girardi LN, Salemi A. Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism. Cardiology 2014; 129:106-10. [DOI: 10.1159/000363647] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 05/11/2014] [Indexed: 11/19/2022]
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Hajj-Chahine J. Resuscitation by extracorporeal membrane oxygenation with or without subsequent embolectomy. Eur J Cardiothorac Surg 2013; 45:1117. [PMID: 23999559 DOI: 10.1093/ejcts/ezt446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jamil Hajj-Chahine
- Department of Cardio-thoracic Surgery, Centre Hospitalier Universitaire de Poitiers, Université de Poitiers, Poitiers, France
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Abstract
Massive pulmonary embolism (PE) is a potentially lethal condition, with death usually caused by right ventricular (RV) failure and cardiogenic shock. Systemic thrombolysis (unless contraindicated) is recommended as the first-line treatment of massive PE to decrease the thromboembolic burden on the RV and increase pulmonary perfusion. Surgical pulmonary embolectomy or catheter-directed thrombectomy should be considered in patients with contraindications to fibrinolysis, or those with persistent hemodynamic compromise or RV dysfunction despite fibrinolytic therapy. Critical care management predominantly involves supporting the RV, by optimizing preload, RV contractility, and coronary perfusion pressure and minimizing afterload. Despite these interventions, mortality remains high.
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Affiliation(s)
- Narain Moorjani
- Department of Cardiothoracic Surgery, Papworth Hospital, University of Cambridge, Cambridge CB23 3RE, UK.
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Numasawa Y, Motoda H, Yamazaki H, Kuno T, Hashimoto O, Takahashi T. Successful percutaneous thrombectomy in an elderly patient with massive pulmonary embolism with cardiogenic shock. Cardiovasc Interv Ther 2013; 29:70-5. [PMID: 23813414 DOI: 10.1007/s12928-013-0194-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 06/17/2013] [Indexed: 11/30/2022]
Abstract
We report on an 80-year-old woman with cardiogenic shock due to massive pulmonary embolism who was successfully treated with percutaneous thrombectomy using a conventional angiographic guide wire and catheters combined with systemic thrombolysis. We successfully treated the patient without a ventilator or extracorporeal life support. We report that percutaneous thrombectomy can provide rapid improvement of hemodynamic instability and can be used as an effective adjuvant therapy for systemic thrombolysis in patients with massive pulmonary embolism. Percutaneous thrombectomy is a less invasive and reasonable alternative to surgical embolectomy for patients with massive pulmonary embolism with cardiogenic shock.
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Affiliation(s)
- Yohei Numasawa
- Department of Cardiology, Ashikaga Red Cross Hospital, 284-1 Yobe-cho, Ashikaga, Tochigi, Japan,
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