Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach.
OBJECTIVE
This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate.


METHODS
Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest.


RESULTS
There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively.


CONCLUSIONS
An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.
Leacche
Marzia
M
Division of Cardiac Surgery, and Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
Unic
Daniel
D
Goldhaber
Samuel Z
SZ
Rawn
James D
JD
Aranki
Sary F
SF
Couper
Gregory S
GS
Mihaljevic
Tomislav
T
Rizzo
Robert J
RJ
Cohn
Lawrence H
LH
Aklog
Lishan
L
Byrne
John G
JG
D000206:Actuarial Analysis; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000075202:Contraindications; D017548:Echocardiography, Transesophageal; D017128:Embolectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D004630:Emergencies; D005260:Female; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D018579:Patient Selection; D016016:Proportional Hazards Models; D011655:Pulmonary Embolism / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000209:etiology; D016019:Survival Analysis; D015912:Thrombolytic Therapy; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D016306:Vena Cava Filters; D018497:Ventricular Dysfunction, Right / Q000209:etiology