Surgical therapy of fulminant pulmonary embolism: early and late results.
BACKGROUND
Pulmonary embolectomy remains the only option for patients with fulminant pulmonary embolism and failure or contraindication of thrombolysis even today. Increasing prevalence of heparin-induced thrombocytopenia type II (HIT) adds a new significant problem, which was investigated in a retrospective study.


METHODS
Between 1/1979 and 1/1998 41 patients (21 male; age: 51.1 +/- 14.8 years) with fulminant pulmonary embolism underwent pulmonary embolectomy under cardiopulmonary bypass: group I (1979-89): 31 patients; group II (1990-98): 10 patients. Group II included only patients who did not meet the criteria for acute thrombolysis, in 4 patients a HIT was preoperatively assured. All patients were in strongly compromised hemodynamic condition (33/41 high-dose catecholamines, 24/41 mechanical ventilation, 14/41 preoperative cardiopulmonary resuscitation).


RESULTS
Perioperative mortality was 29% (group I: 9/31; group II: 3/10; n.s.) Preoperative resuscitation was the only predictive factor (with resuscitation: 9/14; without resuscitation: 3/27; p < 0.001). Severe but not fatal complications occurred in 11 patients: they fully recovered following treatment. Follow-up was completed to 93% (281 patient-years; mean: 10.6 years) and discovered 5 late deaths (late mortality: 1.7%/patient-year; 1 patient: bleeding due to anticoagulation; 4 patients: not related to operation). 26/28 (93%) patients were in NYHA functional class I or II. No recurrent pulmonary embolism or late clinical symptoms related to embolectomy were observed. There was no difference between group I and group II (including the 4 patients with HIT) regarding perioperative mortality, complication, and late results.


CONCLUSIONS
Pulmonary embolectomy on cardiopulmonary bypass remains an adequate therapy in patients with failure of or contraindication to thrombolysis, and HIT is not a contraindication.
Doerge
H
H
Department of Thoracic and Cardiovascular Surgery, RWTH University Hospital, Aachen, Germany.
Schoendube
F A
FA
Voss
M
M
Seipelt
R
R
Messmer
B J
BJ
D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002315:Cardiopulmonary Bypass; D016887:Cardiopulmonary Resuscitation / Q000379:methods; D017128:Embolectomy / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000401:mortality / Q000601:surgery*; D012189:Retrospective Studies; D015996:Survival Rate; D016896:Treatment Outcome; D016306:Vena Cava Filters