title: Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients.
abstract: OBJECTIVE
  Treatment of central and paracentral pulmonary embolism in patients with hemodynamic compromise remains a subject of debate, and no consensus exists regarding the best method: thrombolytic agents, catheter-based thrombus aspiration or fragmentation, or surgical embolectomy. We reviewed our experience with emergency surgical pulmonary embolectomy.
  
  
  METHODS
  Between January of 2000 and March of 2007, 25 patients (17 male, mean age 60 years) underwent emergency open embolectomy for central and paracentral pulmonary embolism. Eighteen patients presented in cardiogenic shock, 8 of whom had cardiac arrest and required cardiopulmonary resuscitation. All patients underwent operation with mild hypothermic cardiopulmonary bypass. Concomitant procedures were performed in 8 patients (3 coronary artery bypass grafts, 2 patent foramen ovale closures, 4 ligations of the left atrial appendage, 3 removals of a right atrial thrombus). Follow-up is 96% complete with a median of 2 years (range, 2 months to 6 years).
  
  
  RESULTS
  All patients survived the procedure, but 2 patients died in the hospital on postoperative days 1 (intracerebral bleeding) and 11 (multiorgan failure), accounting for a 30-day mortality of 8% (95% confidence interval: 0.98-0.26). Four patients died later because of their underlying disease. Pre- and postoperative echocardiographic pressure measurements demonstrated the reduction of the pulmonary hypertension to half of the systemic pressure values or less.
  
  
  CONCLUSIONS
  Surgical pulmonary embolectomy is an excellent option for patients with major pulmonary embolism and can be performed with minimal mortality and morbidity. Even patients who present with cardiac arrest and require preoperative cardiopulmonary resuscitation show satisfying results. Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise.
authors.affiliation: Department for Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland. alexander.kadner@web.de
authors.forename: Alexander
authors.initials: A
authors.lastname: Kadner
authors.forename: Jürg
authors.initials: J
authors.lastname: Schmidli
authors.forename: Florian
authors.initials: F
authors.lastname: Schönhoff
authors.forename: Eva
authors.initials: E
authors.lastname: Krähenbühl
authors.forename: Franz
authors.initials: F
authors.lastname: Immer
authors.forename: Thierry
authors.initials: T
authors.lastname: Carrel
authors.forename: Friedrich
authors.initials: F
authors.lastname: Eckstein
mesh_terms: D001794:Blood Pressure; D002315:Cardiopulmonary Bypass; D016887:Cardiopulmonary Resuscitation; D016638:Critical Illness; D017128:Embolectomy; D004630:Emergencies; D005260:Female; D006323:Heart Arrest / Q000150:complications; D006801:Humans; D008297:Male; D008875:Middle Aged; D011651:Pulmonary Artery; D011655:Pulmonary Embolism / Q000150:complications / Q000601:surgery*; D012770:Shock, Cardiogenic / Q000150:complications; D016896:Treatment Outcome