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Survival and RV Function After Surgery for Acute Pulmonary Embolism
Quick Takes
- Surgical embolectomy and/or ECMO can be used for patients with massive and submassive PE.
- After surgical intervention, patients with acute PE had marked improvement in RV function.
Study Questions:
What is the safety and efficacy of surgical management of acute pulmonary embolism (PE)?
Methods:
The authors conducted a single-center study of 136 patients who underwent surgical embolectomy and/or venoarterial extracorporeal membrane oxygenation (ECMO) for massive and submassive PE between 2005 and 2019. Right ventricular (RV) recovery was assessed through improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular (LV) ratio, and RV fractional area change.
Results:
Of the 136 patients included in the study, 92 had submassive and 44 had massive PE. Patients with massive PE more often presented with syncope (59% vs. 25%, p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% vs. 0%), and failed thrombolysis (18.2% vs. 4.3%, p = 0.008). Preoperative cardiopulmonary resuscitation occurred in 43.2% of patients with massive PE. ECMO was used commonly in patients with massive PE (40.9%). RV function improved following surgery, as measured by changes in central venous pressure (23.4 ± 4.9 mm Hg to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (60.6 ± 14.2 mm Hg to 33.8 ± 10.7 mm Hg), RV/LV ratio (1.19 ± 0.33 to 0.87 ± 0.23, p < 0.005), and fractional area change (from 26.8 to 41.0, p < 0.005). Mortality was 4.4% overall, including 1/92 (1.1%) of submassive PE and 5/44 (11.6%) of massive PE patients.
Conclusions:
The authors concluded that surgical management of massive and high-risk submassive PE is safe and effective at achieving RV recovery.
Perspective:
While the majority of patients with acute PE are managed with anticoagulation alone, much attention recently has been paid to the management of massive and submassive PE (also known as high risk and intermediate-high risk). While use of surgical embolectomy is not routine, some centers employ this strategy more commonly with good results. This study demonstrates that surgical embolectomy and/or use of ECMO can be an effective strategy for RV recovery in the sickest patients with acute PE. However, with the advent of newer catheters for both thrombolysis and thrombectomy, it remains to be seen if these strategies would offer similar efficacy with much less morbidity.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Interventions and Vascular Medicine
Keywords: Anticoagulants, Blood Pressure, Cardiac Surgical Procedures, Cardiopulmonary Resuscitation, Central Venous Pressure, Embolectomy, Extracorporeal Membrane Oxygenation, Glasgow Coma Scale, Pulmonary Embolism, Syncope, Thrombectomy, Thrombolytic Therapy, Vascular Diseases, Ventricular Function, Right
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