Pulmonary Embolectomy: Recommendation for early surgical intervention Tomas A. Salerno, M.D. Professor of Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital
Epidemiology >600,000 patients/year in the US 50,000-200,000 deaths/year in the US 3-month mortality 15-20% 10% of symptomatic PE are fatal at 1 hour
Epidemiology 70% of symptomatic PE have a DVT 50% of patients with a symptomatic DVT have a PE
Age Distribution Goldbaher et al. Lancet (1999)
Virchow s Triad Venous Stasis Hypercoagulability Endothelial Injury
Risk Factors for DVT/PE VENOUS STASIS. immobility (bed rest, travel). paralysis (CVA, SCI). Obesity. heart/respiratory failure. Casting ENDOTHELIAL INJURY. trauma (orthopedic). major surgery (orthopedic). central venous catheters HYPERCOAGULABILITY. previous DVT/PE. malignancy. inflammatory conditions (SLE). sepsis. increased estrogen. acquired/inherited disorders. protein S or C deficiency. ATIII deficiency. factor V Leiden mutation
Clinical Scenario PA obstruction pulmonary vascular resistance (PVR). redistribution of blood flow impairs gas exchange. hyperventilation and bronchoconstriction augments airway resistance. pulmonary edema pulmonary compliance. As RV afterload, RV dilatation/dysfunction and ischemia and subsequent hemodynamic (HD) compromise. cardiac arrest and sudden cardiac death
Clinical Presentation Goldbaher et al. Lancet (1999)
Clinical Scenario
RVD and Mortality Goldbaher et al. Lancet (1999)
In-Hospital Mortality Dalen et al. Arch Irtern Med 2002
Predictor of Mortality RV dilation Normal RV
PA Embolism
PA Embolism
Right Ventricular Distension
Right Ventricular Distension
Specimen
Predictors of mortality
Outcomes Wood et al. Circulation 2002
Traditional PE management
Thrombolytics in Pulmonary Embolism Compared to UFH thrombolytics demonstrate: more rapid improvements in pulmonary vascular resistance improved RV function significantly more bleeding complications Trials all have limitations which include: small sample sizes (8-160 pts) underpowered to evaluate clinical endpoints heterogeneous patient populations
Thrombolytics vs. Surgery Mortality Thrombolytics 33% hemodynamically stable patients with RV dysfunction vs. Pulmonary Embolectomy 11% hemodynamic unstable patients Sukhija et al. Am J Cardiol 2005 33% 23% patients with shock and massive pulmonary Gulba et al. Lancet 1994 Both studies concluded that, medically treated patients, have higher death rate, increased risk of major hemorrhage, and increased recurrence rate of PE.
Pulmonary Embolectomy Past Present and Future Mortality Rates in Earlier Studies of Open Pulmonary Embolectomy Mortality = 8% Mortality = 6%
Surgical Technique: Aorta and Double stage venous cannulation Normothermic CPB with Lung ventilation Main PA opened Oval forcepts removal of clots until clear return Confirmation with TEE of main PA clots removal
Table 1 Patient Characteristics Variables n % Age at surgery 45.31 ± 17.65 (14-76) Gender Male 9 56.2% Female 7 43.7% Procedure Emergent/urgent Salvage Table 1 Patient Characteristics Variables n 9 7% 56.2% 43.7% Age at surgery 45.31 ± 17.65 (14-76) Gender Male 9 56.2% Female 7 43.7% Procedure Emergent/urgent 9 56.2% Salvage 7 43.7% Hospital Stay, days (range) 16.62 ± 16.73 (1-66) Deep Vein Thrombosis 7 43.7% Respiratory Failure 4 25% Hypertension Hospital Stay, days (range) 16.62 ± 16.73 (1-66) 4 25% Renal Failure Deep Vein Thrombosis 7 443.7% 25% Diabetes Respiratory Failure 4 425% 25% Hypertension 4 25% Prior organ transplantation Renal Failure 4 325% 18.7% Congestive Heart Failure Diabetes 4 325% 18.7% Prior organ transplantation 3 18.7% Neoplasia Congestive Heart Failure 3 318.7% 18.7% Prior PE Neoplasia 3 218.7% 12.5% Prior PE 2 12.5% Bacterial endocarditis 1 6.2% Bacterial endocarditis 1 6.2% Hypercoagulable state Hypercoagulable state 1 16.2% 6.2% LVEF 53.43 ± 7.68% ( 40-70 ) EF> 50% 6 37.5% LVEF EF = 31-50% 53.43 10 ± 7.68% 62.5% ( 40-70 ) EF> 50% 6 37.5% EF = 31-50% LVEF (Left Ventricular Ejection Fraction) 10 62.5% LVEF (Left Ventricular Ejection Fraction)
Table 2 Operative Data Variables n % CPB time (min) 43.12 ± 41.65 (9-161) Table 1 Patient Characteristics ICU stay (day) 6.19 ± 5.44 (0-17) Variables n % Age at surgery 45.31 ± 17.65 (14-76) Gender Male 9 56.2% Female 7 43.7% Procedure Emergent/urgent 9 56.2% RV dysfunction Salvage 7 43.7% 7 77.7% Preoperative echo findings (non-salvage patients) Hospital Stay, days (range) 16.62 ± 16.73 (1-66) RV normal 2 22.3% Complications Deep Vein Thrombosis 7 43.7% Respiratory Failure 4 25% Hypertension 4 25% Renal Failure 4 25% Diabetes 4 25% Renal Failure Prior organ transplantation 3 18.7% 2 12.5% Congestive Heart Failure 3 18.7% Re-exploration Neoplasia 3 18.7% 2 12.5% Prior PE 2 12.5% Bleeding Bacterial endocarditis 1 6.2% Hypercoagulable state 1 6.2% 2 12.5% Wound infection 1 6.2% LVEF 53.43 ± 7.68% ( 40-70 ) Cardiac arrest EF> 50% 6 37.5% 1 6.2% EF = 31-50% 10 62.5% LVEF (Left Ventricular Ejection Fraction) CPB (Cardiopulmonary Bypass); ICU (Intensive Care Unit)
Our Findings non-salvage salvage Early Mortality alive dead P=0.011 0 2 4 6 8 No. of patients Figure 2. Early mortality according to surgical modality (salvage vs. non-salvage). P < 0.05. Percent survival 100 75 50 25 salvage non-salvage p<0.05 0 0 10 20 30 40 days Figure 1. Kaplan Meier curves after surgical pulmonary embolectomy. In-Hospital survivals (salvage vs. non-salvage operations). P < 0.05. Mortality = 11% In patients with RVD undergoing early surgical embolectomy
Our Findings Table 4 Stratification of Risk of Death and recommended therapeutic option Risk of In-hospital Death Risk factor Recommended Treatment Cardiogenic Shock RV Dysfunction (based on echocardiogram) High Present Present Surgical Embolectomy Intermediate Absent Present * Consider Surgical Embolectomy Absent Absent Thrombolysis or conservative approach Low Absent Absent LMWH or Foundaparinux; consider outpatient treatment Adapted with modifications from Konstantinides et al.(2) and the 2008 Guidelines of the European Society of Cardiology * Recommendation for early surgical pulmonary embolectomy in hemodynamically stable patients with RV dysfunction