title: Management of massive pulmonary embolism: a retrospective single-centre cohort study.
abstract: BACKGROUND
  Massive pulmonary embolism (PE) (PE associated with hypotension or shock) is a condition with a mortality rate in excess of 50%. Although expert opinion favouring thrombolysis exists, this is based predominantly on studies demonstrating physiological benefits rather than a mortality benefit. The optimal treatment for massive PE remains unclear. The majority of studies to date have studied medical therapy, and case series of surgical pulmonary embolectomy have also been reported. No studies directly comparing mortality between medical and surgical therapies have been published. In our institution, both medical and surgical therapies are used in the treatment of massive PE.
  
  
  OBJECTIVE
  To identify the characteristics and outcomes of patients who received thrombolysis, surgical embolectomy or heparin anticoagulation for management of massive PE.
  
  
  METHODS
  Retrospective cohort study of patients with massive PE at the Royal North Shore Hospital, Sydney, Australia. The hospital medical records database was searched from 1 January 1996 to 31 December 2006. In addition, both the intensive care and cardiothoracic surgery databases were searched for the diagnosis of PE. Patients were included in our study if there was an ICD-9 diagnosis of PE and a review of notes indicated that the criteria for massive PE were met.
  
  
  RESULTS
  Fifty-one patients with massive PE were identified. Nine received embolectomy, 10 thrombolysis and 14 heparin anticoagulation. There were no statistically significant differences in mortality between these three groups, although resource utilisation was higher in the embolectomy group. Eighteen patients received no definitive treatment because of the poor prognosis of their underlying disease. All patients who received no definitive therapy died.
  
  
  CONCLUSIONS
  Massive PE has a high mortality. No significant mortality benefit was associated with any particular therapy. Patients for whom thrombolysis and/or embolectomy are contraindicated may benefit from simple anticoagulation.
authors.affiliation: Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK. nicholas.barrett@gstt.nhs.uk
authors.forename: Nicholas A
authors.initials: NA
authors.lastname: Barrett
authors.forename: Anthony
authors.initials: A
authors.lastname: Byrne
authors.forename: Anthony
authors.initials: A
authors.lastname: Delaney
authors.forename: Michael
authors.initials: M
authors.lastname: Hibbert
authors.forename: Naresh
authors.initials: N
authors.lastname: Ramakrishnan
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use*; D015331:Cohort Studies; D017128:Embolectomy; D005260:Female; D006493:Heparin / Q000627:therapeutic use*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D015996:Survival Rate; D015912:Thrombolytic Therapy; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants; D006493:Heparin