title: Management of acute massive pulmonary embolism: Is surgical embolectomy inferior to thrombolysis?
abstract: BACKGROUND
  Although current guidelines for pulmonary embolism (PE) treatment recommend surgical embolectomy when thrombolysis is contraindicated or has failed, their clinical outcomes rarely have been compared directly.
  
  
  METHODS
  After excluding patients aged under 18 years and those with submassive or non-massive PE, 45 consecutive patients (median age, 68 years; 62% female; 31% experienced cardiac arrest before PE treatment onset; 33% had cancer diagnosis history; and 29% received extracorporeal membrane oxygenation [ECMO]) who underwent only thrombolysis (TL group; n=19) or surgical embolectomy (SE group; n=26, including 4 who had failed thrombolysis) for acute massive PE from 2000 to 2013 at Samsung Medical Center were enrolled to assess cardiac mortality as primary outcome.
  
  
  RESULTS
  Median follow-up duration was 17.2 months. In the SE group, significantly higher proportions of patients had recent surgery and ECMO. Overall 30-day all-cause mortality rate was 24% (n=11), without significant difference between the SE (15%) and TL (37%) groups (P=0.098); however, cardiac mortality rate was significantly higher in the TL than SE group (Log rank P=0.023). TL was an independent multivariate predictor of cardiac death (P=0.03).
  
  
  CONCLUSIONS
  In this small retrospective single center experience, surgical embolectomy is associated with lower cardiac mortality risk than thrombolysis, which might render it first-line treatment option for acute massive PE for patients without life-limiting comorbidities.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Yang Hyun
authors.initials: YH
authors.lastname: Cho
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Kiick
authors.initials: K
authors.lastname: Sung
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea. Electronic address: wooksung.kim@samsung.com.
authors.forename: Wook Sung
authors.initials: WS
authors.lastname: Kim
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Dong Seop
authors.initials: DS
authors.lastname: Jeong
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Young Tak
authors.initials: YT
authors.lastname: Lee
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Pyo Won
authors.initials: PW
authors.lastname: Park
authors.affiliation: Department of Internal Medicine, Division of Cardiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
authors.forename: Duk-Kyung
authors.initials: DK
authors.lastname: Kim
mesh_terms: D000368:Aged; D019468:Disease Management; D017128:Embolectomy / Q000379:methods*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011655:Pulmonary Embolism / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D056910:Republic of Korea / Q000453:epidemiology; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents
keywords: Fibrinolysis; Pulmonary embolism; Shock; Surgical embolectomy