Acute massive pulmonary embolism (AMPE) is lifethreatening

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1 Pulmonry Embolectomy for Acute Mssive Pulmonry Embolism Christine Duphine, MD, nd Bssm Omri, MD Deprtment of Surgery, Division of Crdiothorcic Surgery, Hrbor-UCLA Medicl Center, Torrnce, Cliforni Bckground. Acute mssive pulmonry embolism usully results in deth if not dignosed erly nd treted ggressively. Thrombolytic therpy nd ctheter embolectomy re incresingly used s definitive mngement. Emergent open embolectomy is often reserved s lst resort when less invsive methods hve filed or the ptient is in crdiopulmonry rrest. Methods. We reviewed our experience with erly open pulmonry embolectomy in ptients with cute mssive pulmonry embolism from Jnury 1998 to Februry Results. Eleven ptients underwent erly pulmonry embolectomy. Five (45%) ptients were men, nd the verge ge ws 48 yers. In 4 (36%) ptients, mssive pulmonry embolism occurred fter surgicl procedure or trum. The remining 7 ptients hd chronic medicl diseses. The dignosis ws estblished primrily by clinicl findings long with spirl computerized tomogrphy or trnsesophgel echocrdiogrphy. Eight (73%) ptients survived nd were dischrged from the hospitl. The 3 ptients who died suffered crdic rrest preopertively nd were tken to the operting room with crdiopulmonry resuscittion in progress. Only 1 ptient survived fter preopertive crdic rrest. Conclusions. Erly open pulmonry embolectomy using crdiopulmonry bypss is n effective form of tretment for cute mssive pulmonry embolism with excellent long-term results. Preopertive crdic rrest is ssocited with high mortlity. Spirl computerized tomogrphy nd trnsesophgel echocrdiogrphy re importnt dignostic tools. (Ann Thorc Surg 2005;79:1240 4) 2005 by The Society of Thorcic Surgeons Acute mssive pulmonry embolism (AMPE) is lifethretening nd usully results in deth if not dignosed erly nd treted ggressively. Despite incresed emphsis on prophylxis nd the development of better dignostic nd therpeutic techniques, mortlity ssocited with AMPE remins t bout 30% [1 3]. AMPE comprises s mny s one tenth of ll cses of pulmonry embolism nd is defined s n occlusion of the pulmonry rtery tht exceeds 50% of its cross-sectionl re, resulting in progressive hemodynmic compromise [4 7]. The obstruction of the pulmonry rtery to this degree initites cscde of physiologic events, which if not interrupted erly, ultimtely results in crdic rrest nd deth in up to 70% of ptients in the first hour [1, 5, 7]. Thrombolytic therpy nd ctheter thromboembolectomy hve proven effective in restoring hemodynmic stbility in ptients with AMPE nd hve been incresingly used s definitive mngement of these ptients [2, 8, 9]. However, these procedures re ssocited with n incresed risk of hemorrhge, recurrent emboli, nd filure to completely resolve the intrluminl thrombus, putting ptients t higher risk to develop pulmonry hypertension [2, 3, 10]. On the other hnd, dvnces in surgicl nd nesthetic techniques, long with the ddition of crdiopulmonry bypss (CPB), hve improved the survivl nd long-term Accepted for publiction Aug 30, Address reprint requests to Dr Omri, 1000 W Crson St, Box 423, Torrnce, CA 90509; e-mil: bomri@ucl.edu. outcome of ptients undergoing erly open pulmonry embolectomy [1, 3, 4, 11]. Open embolectomy is often reserved for ptients in extremis or when less invsive mesures hve filed, but its true role hs not yet been well-chrcterized nd is likely underestimted. This study nlyzed the use of erly open pulmonry embolectomy in ptients with AMPE t n urbn public hospitl in Los Angeles over 6-yer period. Mteril nd Methods A retrospective review ws performed of ll ptients with AMPE who underwent emergency pulmonry embolectomy t Hrbor-UCLA Medicl Center from Jnury 1998 to Februry Ptient demogrphics, risk fctors, modes of dignosis, opertive procedures, nd postopertive morbidity nd mortlity were recorded nd nlyzed. The use of prophylctic mesures, thrombolytics, nd intrcvl filters ws lso exmined. Surgicl Technique All opertions were performed through medin sternotomy. After pericrdiotomy nd systemic hepriniztion, the scending ort nd right tril ppendge were cnnulted for the institution of CPB. A longitudinl incision ws then mde in the pulmonry rtery, followed by removl of clot with ring forceps nd vigorous irrigtion of the pulmonry rteril tree. A choledochoscope ws used to identify residul distl clots, which were then extrcted. An inferior ven cv filter ws 2005 by The Society of Thorcic Surgeons /05/$30.00 Published by Elsevier Inc doi: /j.thorcsur

2 Ann Thorc Surg DAUPHINE AND OMARI 2005;79: EMBOLECTOMY FOR PULMONARY EMBOLISM 1241 Tble 1. Chrcteristics nd Outcomes of Ptients with Acute Mssive Pulmonry Embolism Who Underwent Open Pulmonry Embolectomy Ptient Sex Dignosis History of DVT Imging Thrombolytics Crdic Arrest CPB Survivl 54 M Stroke within 60 dys CT, Angio CI 53 Yes 53 M Protein C deficiency Yes Angio Yes 51 Yes 59 M Lower GI bleed; history of stroke BS V/Q, BS Echo CI Yes 62 Yes 41 F POD 1 Cesren section TEE Yes Yes 26 M GSW to bd; POD 26 lprotomy Yes CT, TEE CI 75 Yes 49 F Loclly dvnced lung crcinom BS Echo, TEE Yes 60 F Brin tumor; POD 35 resection Yes CT CI Yes 46 F Obese, smoker, Protein S Yes CT BS Echo 36 Yes deficiency 49 M Elevted homocystine CT, Angio, TEE Yes 86 Yes 52 F Advnced heptocellulr cncer CT, BS Echo 45 Yes 44 F GSW to chest; nonopertive BS Echo, TEE CI 70 Yes Unble to come off bypss. bd bdomen; Angio ngiogrphy; BS bedside; CI contrindicted; CPB crdiopulmonry bypss in minutes; CT spirl computerized tomogrphy; DVT deep venous thrombosis; Echo echocrdiogrphy; F femle; GSW gunshot wound; M mle; POD post op dy; TEE trnsesophgel echocrdiogrphy; V/Q ventiltion/perfusion. inserted by the interventionl rdiologists within 24 hours postopertively in ll ptients. Results Fig 1. Spirl computed tomogrphy shows mssive embolus in the right pulmonry rtery. From Jnury 1998 to Februry 2004, 11 ptients with AMPE underwent erly pulmonry embolectomy (Tble 1). Five (45%) ptients were men, nd the verge ge ws 48 yers (rnge, 26 to 60 yers). Three ptients hd undergone surgicl procedures between 1 nd 35 dys prior, one of which ws trum relted. One other ptient suffered gunshot wound to the chest tht did not require opertive intervention. Three ptients hd been dignosed with cncer, one of which hd recently undergone resection. Three other ptients hd documented hypercogulble conditions, nd 2 ptients hd history of stroke with no identifible hypercogulble predispositions. Seven (64%) were inptients t the time of symptom onset, nd only 3 were receiving prophylxis for venous thrombosis. Two ptients were trnsferred from n outside fcility fter computerized tomogrphy (CT) scns confirmed the dignosis of pulmonry embolism. Four ptients presented to the emergency room with cute onset of shortness of breth nd chest pin. Spirl CT of the chest with intrvenous contrst (Fig 1) ws the initil dignostic study in 6 ptients. Angiogrphy ws performed in 3 ptients nd ws the only dignostic study used in 1 ptient. Eight ptients underwent bedside echocrdiogrphy or intropertive trnsesophgel echocrdiogrphy (TEE), or both. Bedside ventiltion-perfusion scnning ws performed in 1 ptient nd reveled evidence of pulmonry embolism, but evlution by echocrdiogrm ws still necessry before embolectomy. ptient ws tken to the operting room on clinicl suspicion lone. Crdic rrest occurred preopertively in 4 ptients, ll of whom required intermittent crdiopulmonry resuscittion (CPR) en route to the operting room. The rest of the ptients were hypotensive nd tchycrdic, nd 4 required vsopressor support. Thrombolytic therpy ws initited in 3 ptients before open embolectomy. Two of these ptients hd sudden worsening of respirtory filure fter thrombolytic infusion nd required n emergency embolectomy. The third ptient s hemodynmic stte showed no improvement nd n urgent pulmonry embolectomy ws performed. Thrombolytics were otherwise contrindicted in 5 ptients becuse of recent trum, stroke, surgery, nd mjor gstrointestinl hemorrhge. Eight (73%) ptients survived nd were dischrged home. Three ptients, who hd suffered crdic rrest

3 1242 DAUPHINE AND OMARI Ann Thorc Surg EMBOLECTOMY FOR PULMONARY EMBOLISM 2005;79: Tble 2. Mortlity Rtes in Erlier Studies of Open Pulmonry Embolectomy Yer Author Totl Deths preopertively, died intropertively fter embolectomy when they could not be wened off of CPB becuse of poorly contrcting, dilted right ventricles. Only one (25%) of the 4 ptients with crdic rrest before opertion survived. The verge time on CPB ws 60 minutes (rnge, 36 to 86 minutes) for ptients ble to be wened off bypss. The men systolic pulmonry rteril pressure ws 63.3 mm Hg 11.8 mm Hg preopertively nd 33.7 mm Hg 9.1 mm Hg postopertively. Men follow-up time ws 9 months, nd ll dischrged ptients survived t lest 30 dys postopertively. Seven (88%) of the ptients dischrged home were plced on long-term nticogultion with wrfrin. Anticogultion ws contrindicted in the eighth ptient secondry to recent mjor gstrointestinl bleed. One ptient required opertive dringe of persistent wound hemtom 2 months postopertively. Another ptient suffered myocrdil infrction 1 month fter surgery nd required second opertion for repir of n tril septl defect tht ws not seen on prior echocrdiogrm. The postopertive courses for 2 other ptients were complicted by pneumoni in 1 nd cute renl filure in the other, both of which resolved with medicl mngement. Comment Mortlity % 1978 Tschirkov (Germny) Clrk (Englnd) Glssford (Englnd) Bottzuw (Denmrk) Mttox (US) Achtzy (Germny) Jumin (Frnce) Gry (Englnd) Meyer (Frnce) Boulfendis (US) Kieny (Frnce) Schmid (Germny) Buer (Switzerlnd) Meyns (Belgium) Stutz (Switzerlnd) Jkob (Germny) Doerge (Germny) Ullmnn (Germny) Totl The pthophysiology of right ventriculr filure secondry to pulmonry embolism ws described in detil by Vlhkes nd collegues 20 yers go [12]. As the pulmonry rteries become obstructed, the incresed fterlod cuses right ventriculr strin nd dilttion, mking contrctions incresingly difficult for the right ventricle. Displcement of the interventriculr septum combined Fig 2. Totl number of deths reported in the literture in ptients with cute mssive pulmonry embolism with respect to the need for crdiopulmonry resuscittion (CPR). with pulmonry vsoconstriction result in further decreses in crdic output nd blood oxygen content. As result, the dilted, dysfunctionl right ventricle becomes incresingly ischemic s its oxygen demnd outweighs the supply. An endless cycle of poor coronry perfusion nd worsening right ventriculr filure will eventully led to crdic rrest nd deth. Interruption of this cycle by immedite nd complete removl of the obstruction with normliztion of right hert pressures is the only option for good outcome. Resumption of pulmonry rtery flow hs been ccomplished successfully by open pulmonry embolectomy since the first reported cse in 1924 [13]. However, less invsive strtegies hve become incresingly populr, nd open embolectomy is often currently reserved for ptients lredy in crdic rrest or for those in which less invsive therpies re contrindicted or hve filed. Despite n incresing proportion of the sickest ptients undergoing open pulmonry embolectomy, mortlity rtes remin just bove 30% for AMPE (Tble 2) [1, 7, 11, 14 28]. Definitive restortion of pulmonry rtery ptency is ccomplished nd recurrence rtes re low when intrcvl filters re plced immeditely fter embolectomy. CPB offers dditionl benefit to the ptient by restoring oxygention nd correcting hypothermi, cidemi, nd electrolyte bnormlities to improve the stbility of the hert postopertively. If preopertive crdic rrest ws voided, survivl fter open pulmonry embolectomy in this series ws 100%. Similr results re reported in the literture, with n overll mortlity of 57% for ptients requiring crdiopulmonry resuscittion compred with 12% for those who do not (Fig 2) [1, 15, 20 24, 26 28]. Thrombolytic gents trget fibrin bonds nd lyse orgnized clot to restore blood flow in rteries obstructed by thrombus. Although shown to be efficcious in the setting of AMPE, ssocited long-term morbidity my be high, nd gents re contrindicted in up to 50% of ptients becuse of recent surgery, trum, stroke, hemorrhge, or crdiopulmonry resuscittion [2, 29]. Gulb nd collegues showed tht ptients treted with thrombolytics hd higher rtes of deth, mjor hemorrhge, nd recurrent embolism thn their surgicl counterprts [2].

4 Ann Thorc Surg DAUPHINE AND OMARI 2005;79: EMBOLECTOMY FOR PULMONARY EMBOLISM 1243 Perhps the gretest concern is the dely in definitive mngement tht occurs when tril of thrombolytics fils nd the condition of the ptient worsens. Emergency opertive intervention in the fce of recent thrombolytic infusion is significntly more chllenging, nd the risk of postopertive bleeding is incresed. The use of ntifibrinolytic gents nd cryoprecipitte infusions long with meticulous surgicl hemostsis cn help to minimize hemorrhgic complictions; however, overll blood loss cn be significnt. Ctheter thromboembolectomy is minimlly invsive technique where clot is removed by suction through ctheter inserted through the jugulr or femorl vein into the pulmonry rtery. Although successful mngement of AMPE hs been reported, this dvnced technique is not lwys redily vilble, nd ptients my be deemed too hemodynmiclly unstble to fford the time for preprtion nd repeted ctheter insertions to remove mssive clots. Only 5 hve been performed t Hrbor-UCLA Medicl Center in the pst 6 yers. Furthermore, frgmenttion of clot in the min pulmonry rtery with distl showering of emboli to smller inccessible rteries my occur, nd recurrence of the embolus is more common fter this procedure thn with open pulmonry embolectomy [2, 30]. Incomplete embolectomy hs been shown in some ptients to led to pulmonry hypertension over time, which hs been correlted with decresed overll survivl [31, 32]. We propose the following lgorithm for the indictions of the discussed procedures in the setting of AMPE: Ptients with lrge thrombus demonstrted in the pulmonry rtery, ssocited with hemodynmic instbility requiring vsopressor support nd evidence of impending right ventriculr filure, should be promptly tken to the operting room for open embolectomy through sternotomy. Ptients with only mild hemodynmic instbility nd without evidence of severe right ventriculr strin should be considered for thrombolytic therpy if no contrindictions re present. Seril echocrdiogrms should be performed to evlute for improvement. If thrombolytic therpy is contrindicted nd ctheter thrombectomy is redily vilble, then considertion for this technique is pproprite. However, in the instnce tht ptient with lrge proximl thrombus is hemodynmiclly stble but cnnot receive thrombolytics nd ctheter thrombectomy is not vilble, open embolectomy is then indicted. In hemodynmiclly compromised ptients, spirl CT nd TEE re invluble tools for dignostic evlution nd choosing the pproprite therpeutic strtegy [33 35]. Spirl CT is quick, noninvsive, nd highly sensitive for the detection of n embolus in the proximl pulmonry rteril vsculture. Echocrdiogrphy is lso quick nd redily vilble nd cn be performed t the bedside or in the operting room. Right ventriculr dilttion, bnorml right ventriculr wll movement, dilted pulmonry rtery, nd n increse in tricuspid regurgitnt velocity cn be esily evluted to ccurtely predict the degree of right ventriculr filure. The finding of impending filure is n indiction for open pulmonry embolectomy to void subsequent crdic rrest, which is overwhelmingly ftl in this group of ptients. In conclusion, open pulmonry embolectomy is n immedite nd definitive form of tretment for AMPE, with excellent long-term results. CPB is vitl component for the erly resuscittion of these ptients tht increses the likelihood of successful outcome. Open embolectomy before right ventriculr ischemi nd crdic rrest ensues is impertive becuse preopertive crdic rrest is ssocited with the highest mortlity in ptients with AMPE. Furthermore, bedside TEE nd spirl CT re importnt noninvsive dignostic tools tht minimize dely in dignosis without compromising ccurcy. References 1. Stulz P, Schlpfer R, Feer R, Hbicht J, Grdel E. 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