title: Massive pulmonary embolism: surgical embolectomy versus thrombolytic therapy--should surgical indications be revisited?
abstract: OBJECTIVE
  The treatment of massive pulmonary embolism (PE) is a matter of debate. We present our institutional experience of patients suffering from massive PE with the aim of comparing the early results, the outcome and quality of life (QoL) between patients primarily assigned to either pulmonary surgical embolectomy (SE) or thrombolytic therapy (TL). A subgroup of patients (TS) with failed responses to TL requiring SE was separately analysed.
  
  
  METHODS
  All consecutive patients (January 2001-December 2007) with computed tomography (CT)-scan-confirmed massive bilateral central or paracentral PE were reviewed. All clinical data were retrieved from our patients' registry and completed by the evaluation of the CT-scan-derived right ventricle/left ventricle ratio (RV/LV ratio). Follow-up focused on clinical outcome and QoL was obtained.
  
  
  RESULTS
  Eighty patients were analysed including 28 SE (35%) and 52 TL (65%), of whom 11 (21%) required TS. Demographics and preoperative characteristics were similar between SE and TL. Analysis of the RV/LV ratio revealed a ratio of 1.66 for SE and 1.44 for TL. The early mortality rate was not significantly different between the two groups (SE: 3.6% versus TL: 13.5%), whereas early mortality was 27% in those patients treated initially with thrombolysis and subsequently requiring SE (TS-group). Severe bleeding complications were lower in the SE-group (3.6% versus 26.5% P = 0.013). Intracerebral bleeding rates and neurological events were not statistically different. After a mean follow-up of 63 ± 21 months, the mortality rate was 17.9% in the SE-group and 23.1% in the TL-group.
  
  
  CONCLUSIONS
  SE is an excellent treatment option in massive PE with comparable early mortality rates and significantly less bleeding complications than TL. Patients having surgery after inefficient thrombolysis have the worst early outcome. The RV/LV CT-scan ratio might serve as a predictor to differentiate patients, who could profit from direct surgical intervention than thrombolytic treatment attempts. Further studies are required to confirm these results.
authors.affiliation: Department of Cardiovascular Surgery, Berne  University Hospital, University of Berne, Berne,  Switzerland.
authors.forename: Thierry
authors.initials: T
authors.lastname: Aymard
authors.forename: Alexander
authors.initials: A
authors.lastname: Kadner
authors.forename: Alexandra
authors.initials: A
authors.lastname: Widmer
authors.forename: Reto
authors.initials: R
authors.lastname: Basciani
authors.forename: Hendrik
authors.initials: H
authors.lastname: Tevaearai
authors.forename: Alberto
authors.initials: A
authors.lastname: Weber
authors.forename: Jürg
authors.initials: J
authors.lastname: Schmidli
authors.forename: Thierry
authors.initials: T
authors.lastname: Carrel
mesh_terms: D017128:Embolectomy / Q000379:methods*; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D011655:Pulmonary Embolism / Q000188:drug therapy* / Q000601:surgery*; D011788:Quality of Life; D012189:Retrospective Studies; D015912:Thrombolytic Therapy / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome