PURPOSE: Pulmonary embolism remains a common and lethal disease. Predictors of death include hemodynamic instability and RV strain. Thrombolytics are frequently contraindicated or ineffective. Surgical pulmonary embolectomy offers a safe and effective way of preventing death and pulmonary hypertension, with low mortality.
METHODS: We have performed surgical pulmonary embolecomy on all patients presenting with hemodynamic instability and right ventricular strain. Median sternotomy approach with cardiopulmonary bypass is used on all patients. Normothermia, no cardioplegic arrest with warm beating heart is used on the acute embolism patients. Profound hypothermic circulatory arrest is used on the chronic, thromboendartectomy patients. Features of surgery are avoidance of ischemic injury to a stunned right ventricle, keeping the right heart un-loaded and well perfused, and avoidance of blind instrumentation and mechanical injury to the pulmonary arterial wall, and avoidance of pulmonary air entrapment. Four of the acute patients had a trial of tPA. Echocardiography was done as follow-up post thrombolytics to determine response to therapy.
RESULTS: 27 embolectomies in 26 patients was performed over a 4 year period. 22 were acute emergency embolectomies and 5 elective thromboendartectomies. There were 2 hospital deaths in the acute group for a mortality of 9.5%. There have been no late deaths in either group with a mean follow-up period of 18 months.All the patients discharged alive are home. The acute embolism patients have not had evidence of RV dysfunction or chronic disability. All the chronic thromboendartectomy patients have improvement in quality of life indicators and decreased home oxygen dependency.
CONCLUSION: Present surgical techniques for pulmonary embolectomy allow for a safe and effective therapy that focuses on right ventricular preservation, and avoidance of trauma and edema of the pulmonary arteries and parenchyma. Surgery may be appropriate for life-threatening pulmonary embolism where thrombolytics are either contraindicated or ineffective.
CLINICAL IMPLICATIONS: Current surgical pulmonary embolectomy techniques no longer confines this operation to a treatment of last resort.
DISCLOSURE: Alan Hartman, No Financial Disclosure Information; No Product/Research Disclosure Information