title: Outcomes-based systematic review for management of massive intra-cardiac or pulmonary thrombotic emboli during surgery.
abstract: BACKGROUND
  The management of massive intra-operative embolism remains controversial. Our hypothesis was that either surgical or medical thrombectomy offers survival benefit in these patients.
  
  
  METHODS
  Published case reports were reviewed for intra-operative intra-cardiac or pulmonary embolism and outcomes for the following four intervention groups were evaluated for mortality benefit: surgical embolectomy; thrombolysis; anticoagulation; supportive care alone. We also assessed whether the use of diagnostic modalities prior to each embolism event resulted in a mortality benefit and, separately, whether post-intervention improvement in physiologic parameters resulted in improvement in outcomes. Univariate analyses and logistic regression were performed to assess the impact of the four primary interventions on mortality, the primary outcome.
  
  
  RESULTS
  Seventy-eight cases were reviewed and therapeutic interventions resulted in improved survival (70%) compared to supportive care (45%), odds ratio=0.38[0.15-0.98], p=0.04. Univariate analysis of primary interventions with death as a primary outcome resulted in a lack of significantly different outcomes (p=0.08). Mortality rates were 71% in the thrombolytic; 28% in surgical embolectomy; 18% in anticoagulation and 43% in the supportive care groups. The routine pre-event use of trans-esophageal echocardiography was not related with improved outcomes (p=0.36) but the use of pulmonary artery or central venous catheters was (p=0.035). Post-intervention improvements in the physiologic parameters of each diagnostic modality were associated with an improvement in mortality (p<0.05).
  
  
  CONCLUSIONS
  Our data present some important trends among the intervention groups, raising significant concerns about the safety for the use of thrombolytics in the management of intra-operative embolism.
authors.affiliation: Department of Anesthesiology, University at Buffalo, Buffalo, NY.
authors.forename: O
authors.initials: O
authors.lastname: Visnjevac
authors.affiliation: Department of Anesthesiology, University of Toronto School of Medicine, Toronto, Ontario, Canada.
authors.forename: K
authors.initials: K
authors.lastname: Lee
authors.affiliation: Department of Family Medicine, University of Toronto School of Medicine, Toronto, Ontario, Canada.
authors.forename: R
authors.initials: R
authors.lastname: Bulatovic
authors.affiliation: Department of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran.
authors.forename: L
authors.initials: L
authors.lastname: Pourafkari
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, University at Buffalo, Buffalo, NY.
authors.forename: J
authors.initials: J
authors.lastname: Porhomayon
authors.affiliation: Departments of Anesthesiology and Surgery, University at Buffalo, Buffalo, NY.
authors.forename: N D
authors.initials: ND
authors.lastname: Nader
keywords: case; intra-cardiac; intra-operative; outcome; pulmonary emboli; review