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J Thorac Cardiovasc Surg 2005;129:1018-1023
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Modern surgical treatment of massive pulmonary embolism: Results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach

^a Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Mass
^b Cardiovascular Division, Brigham and Women’s Hospital, Boston, Mass
^c Department of Cardiothoracic Surgery, Mount Sinai Medical Center, New York, NY

Read at the Thirtieth Annual Meeting of The Western Thoracic Surgical Association, Maui, Hawaii, June 23–26, 2004.

Received for publication April 20, 2004; revisions received October 15, 2004; accepted for publication October 28, 2004.

^_* Address for reprints: John G. Byrne, MD, C/O Division of Cardiac Surgery, Brigham & Women’s Hospital, 75 Francis St, Boston MA 02115 (E-mail: LCOHN{at}PARTNERS.ORG).

OBJECTIVES: This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate.

METHODS: Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24–86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest.

RESULTS: There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3–75 days). Median follow-up was 27 months (range, 2–50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years’ follow-up was 86% and 83%, respectively.

CONCLUSION: An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

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