AHA Statement on Surgical Management in High-Risk Pulmonary Embolisms: Key Points

Goldberg JB, Giri J, Kobayashi T, et al.
Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2023;Jan 23:[Epub ahead of print].

The following are key points to remember from this American Heart Association (AHA) Scientific Statement on surgical management and mechanical circulatory support (MCS) in high-risk pulmonary embolisms (PEs):

  1. Embolectomy and cardiopulmonary bypass (CPB) are two established modalities for mechanical disruption and diverting the right ventricular (RV) preload in high-risk PE, respectively, causing the distention.
  2. Further research is needed to determine more accurate predictors of patient stability because systemic blood pressure, which is currently used to risk-stratify patients, may be inadequate for selecting patients who may decompensate.
  3. Anesthesia induction can be hazardous because most anesthetics lead to a loss of adrenergic tone, resulting in a cycle of decreased venous return and perfusion pressure, which, unless intervened on rapidly, may culminate in profound hemodynamic instability and cardiac arrest.
  4. Most morbidity and mortality associated with surgical embolectomy are associated with preoperative cardiopulmonary resuscitation (CPR). The mortality of surgical embolectomy patients who do not require CPR is roughly equivalent to the average mortality associated with coronary artery bypass grafting across a wide range of patient risks.
  5. Modern surgical embolectomies are performed on CPB with variability in techniques. Future research is needed to determine the impact of heterogeneous surgical techniques and strategies, especially focusing on the timing of CPB given the instability that patients experience after anesthesia induction.
  6. Uniform and validated assessment of RV function is needed within the PE literature to facilitate comparative studies. Failure of systemic thrombolysis is associated with compromised post–surgical embolectomy outcomes. Future investigation is needed to identify patients who are likely to fail systemic thrombolysis primarily to select a more efficacious treatment modality.
  7. More accurate classification of the characteristics of preoperative CPR is needed in future PE research. Future research should attempt to determine whether extensive SE prevents chronic thromboembolic pulmonary hypertension and other post-PE syndromes.
  8. The vast majority of patients with acute PE receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) are high risk, with a high proportion of patients requiring preoperative CPR. Given the high acuity of patients receiving VA-ECMO and the high proportion of salvage patients, RV recovery may be a better metric of treatment success than survival.
  9. Emerging percutaneous RV MCS with or without an associated oxygenator can be used to support a failing RV. Data on their efficacy in the setting of PE are limited.
  10. A patient who is classified as high risk on the basis of a 40 mm Hg drop in baseline blood pressure is different from a patient who is defined as high risk because of ongoing CPR. To better risk-stratify patients, compare treatment modalities, and risk-adjust outcomes, more precise strata reflecting patients’ hemodynamic and clinical status are necessary to separate the population with salvage/fulminant PE from the high-risk population.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and Heart Failure, Acute Heart Failure, Pulmonary Hypertension, Interventions and Vascular Medicine, Hypertension

Keywords: Anticoagulants, Blood Pressure, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Cardiopulmonary Resuscitation, Embolectomy, Extracorporeal Membrane Oxygenation, Hemodynamics, Heart Arrest, Heart Failure, Hypertension, Pulmonary, Oxygenators, Pulmonary Embolism, Risk, Thrombolytic Therapy, Vascular Diseases

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