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J Thorac Cardiovasc Surg 2005;129:1018-1023
© 2005 The American Association for Thoracic Surgery
Surgery for Acquired Cardiovascular Disease |
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).
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Abstract |
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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.
In the past, surgical pulmonary embolectomy has usually been reserved for patients with massive PE who present in cardiogenic shock. This approach is associated with high mortality rates, ranging from 16% to 64%.3,4 In October 1999,5 we liberalized the indications of surgical embolectomy for acute PE at our institution to include patients with large anatomically extensive clot and moderate-to-severe right ventricular dysfunction (RVD) without shock to improve early and late survival in this condition.5 The rationale for this approach is based on numerous observations that implicate RVD as an early and late risk factor for right ventricular (RV) failure, RV ischemic infarction,6 and death.7
Our multidisciplinary approach is based on rapid diagnosis with computed tomography (CT) and echocardiography to identify patients with severe RVD and likely poor early outcome.5,8 In this article we present our series of 47 consecutive patients who underwent surgical pulmonary embolectomy over a 4-year period.
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Surgical technique |
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Statistical analysis |
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Results |
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Three (6%) patients died within 30 days of the operation. A 50-year-old man died on postoperative day 19 after recurrent PE and severe RV failure and before we adopted the routine use of caval filters. Reoperative embolectomy with RV assist device placement was not successful. A 34-year-old man who previously underwent knee arthroscopy presented in cardiac arrest. He did recover hemodynamically after pulmonary embolectomy but never regained consciousness and was declared brain dead on the second postoperative day. The third patient was an 84-year-old woman who presented for embolectomy with worsening hypoxia after thrombolytic treatment failure. She experienced aortic dissection during cannulation and died as a result of intractable bleeding after aortic repair.
Two (4%) patients had reoperations for mediastinal bleeding, and 2 (4%) had deep sternal wound infections. An RV assist device was implanted in 2 (4%) patients, one of whom was successfully weaned.
Median follow-up was 27 months (range, 2–50 months), and follow-up was 100% complete in 44 surviving patients. There were 6 (12%) late deaths. Actuarial survival at 1 and 3 years’ follow-up was 86% ± 5% (CI, 0.70–0.90) at 1 year and 83% ± 6% (CI, 0.66–0.92) at 3 years, respectively (Figure 3). Five of the 6 patients with late deaths were given diagnoses of cancer at the time of surgical embolectomy.
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Thrombolytic treatment offers a more rapid rate of resolution of pulmonary emboli than the standard treatment with heparin alone and is indicated in patients with massive PE. There are, however, few studies focusing on the long-term outcome of patients who receive thrombolysis treatment and no data comparing surgical and medical treatment in patients eligible for both treatments.11–13
Catheter embolectomy as a therapeutic modality can be performed during contrast pulmonary angiography. However, commercially available catheters tend to fragment the embolus rather than extracting it,2 causing the embolus particles to propagate further into the pulmonary circulation, thus placing patients at risk for subsequent pulmonary hypertension.
Identification of a central surgically accessible PE (within the main trunk or left or right main PA) is required before considering surgical therapy. The best surgical candidates are those patients with a large amount of clot limited to the central main branches. Patients with most of their clot burden located peripherally do not do well with surgical intervention. Patients with central clotting that extends peripherally do well with surgical intervention, but the surgeon must be prepared to systemically cool on CPB to permit modulation of CPB flows for better visualization during clot removal.
We have extended the indications for surgical intervention beyond the traditional indications for massive PE (ie, failure of lytic treatment or hemodynamic compromise) to include hemodynamically stable patients with massive central clot burden and signs of RVD on echocardiogram. The latter represents a controversial group.11,12 Our approach was recently replicated by Yalamanchili and colleagues,14 with 8% mortality. Development of shock and multisystem organ failure as a consequence of RV failure is associated with at least 30% mortality, whereas if cardiac arrest occurs, mortality approaches 70%.7
A decrease of mortality in surgical PE series from 57% in the 1960s15 to 26% in the 1990s16 to 6% in our series has been documented. In the past, pulmonary embolectomy was the treatment of last resort for patients with PE because it was associated with high mortality. The average morbidity from different series between 1982 and 1999 is about 30%.14 This approach has changed over time. Increasingly more often, centers are reporting PE as an integral part of their treatment algorithm for patients with both massive and submassive PE, where massive PE is defined as the presence of persistent systemic hypotension or cardiogenic shock and signs of RVD, and submassive PE is defined as moderate-to-large clot, presence of RVD, and normal arterial blood pressure.17
Very few studies have compared medical versus surgical treatment for PE. In a nonrandomized comparison of surgical and medical treatment in hemodynamically compromised patients with massive PE, the medical group had an increased mortality rate, increased number of hemorrhagic events, and a higher rate of recurrent PE.18
Significantly higher mortality rates are observed in patients who undergo cardiopulmonary resuscitation (CPR).7 Furthermore, patients brought to the operating room undergoing continuous CPR have a higher mortality than those undergoing intermittent CPR with stable hemodynamics on arrival to the operating room (80% vs 40%, respectively).19 We experienced similar findings with our cohort. Six patients had cardiac arrest and required CPR, of whom 2 died. One patient had recurrent PE in the hospital and experienced a cardiac arrest. The other patient was transferred from an outside hospital under continuous CPR, which continued until the operation, and spontaneous rhythm was never established preoperatively. These results raise questions about the appropriateness of aggressive surgical therapy with out-of-hospital cardiac arrest and prolonged unsuccessful CPR. RVD without shock is a controversial, but we believe reasonable, indication for surgical embolectomy, because as PA-RV pressures increase, the right ventricle might ultimately fail. RV ischemia caused by interatrial septum displacement might reduce coronary artery perfusion to the right ventricle, which can cause RV ischemic infarction and death.6,7
Another controversial issue centers around the perioperative placement of a vena caval filter. The recurrence rate of PE after surgical pulmonary embolectomy is as high as 5%.3 In a randomized trial assessing use of inferior vena caval filter placement versus no filter in patients with proximal deep-vein thrombosis, there were no differences in early or late mortality.20 However, the same study revealed the initial efficacy of filters for the prevention of PE in the first year. Because one of our first patients experienced a fatal recurrent PE, we now always place a vena caval filter at the time of surgical pulmonary embolectomy.
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Discussion |
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Dr Byrne. It is all individualized. In an elderly person with comorbidities, we probably would not want to do the operation. All we have are the ones whom we operated on, so the ones who did have cardiac arrest, I think 6 of the 47, were typically young, otherwise healthy people who were previously healthy and had CPR. Now we appreciate that getting someone back is a tough problem because they do not oxygenate their blood very well, and they could end up brain dead. In fact, 2 of the 6 patients did die here, and therefore there was a 33% operative mortality instead of 6% overall. I agree it is a controversial area, but it is all individualized. For a young, otherwise healthy person, I think you should give that person a shot.
Dr Yun. Although only 3 patients died within 30 days of operations, according to your article, another patient could not be weaned from RV assist device, giving a hospital mortality of 8.5%. How many of the 5 late deaths were actually in-hospital deaths beyond the 30-day period?
Dr Byrne. The RV assist device was weaned in that patient. It was able to be weaned, but your question is how many out beyond 30 days? Well, we have the late, 2-year follow-up. We have 100% follow-up out to a median of 2 years, and there were 6 late deaths; 5 of 6 had cancers.
Dr Yun. Regarding the subset of 15 patients with preserved arterial pressure but significant RVD, did the decision to operate rely solely on echocardiographic findings or was it based on a risk stratification scheme, such as the Geneva Prognostic Index, or additionally guided by the use of biomarkers, such as troponin and B-type natriuretic peptides?
Dr Byrne. That is a good question. We did not use any of the biomarkers. In the patients on whom we operated, all were symptomatic. About a third were hemodynamically stable, but their sole indication other than symptoms was impending RV failure, as documented by those echocardiograms that showed massively dilated dysfunctional RV. We do not have data on how many patients in whom we said, okay, their right ventricle is not that bad, let’s hold off, but that is something that we need to do.
Dr Yun. To be the devil’s advocate, in the Management Strategy and Prognosis of Pulmonary Embolism 3 trial comparing thrombolysis plus heparin with heparin alone in stable patients, the overall mortality was 2.7%, without significant differences between the 2 treatment arms. Unfortunately, the report does not specify the mortality rate of patients with impending hemodynamic instability because of RVD, which constituted about 30% of the cases, the same as in your series, which was about 32%. However, even if one assumes that all deaths occur in this subset of patients, the worst-case mortality would still be at a respectable 8.5%. Compared with the 6.5% in this series, what is the rationale for operation in the stable patient with RVD without some sort of a randomized trial unless there is a contraindication to thrombolysis?
Dr Byrne. That is a really good question. I think it comes down to a multidisciplinary approach that many cardiologists have bought into because they believe the operation is very effective and safe. I think it is just going to take some education, debate, and eventually a randomized trial to figure this one out. To be able to stratify RVD, we all need that denominator that we talked about before—the people with RVD but who did not undergo an operation—and see what their outcome was.
Dr Scott Mitchell (Stanford, Calif). We have a very aggressive group of interventionalists at Stanford, and therefore if we see these patients in the condition in which they are still clinically stable but have a contraindication to heparin or systemic thrombolysis, then we undergo regional thrombolysis with some of these mechanical devices. This seems like the perfect milieu when the patients are still stable. My question is, do you have experience with those devices, and do you have the same aggressive interventionalists?
Dr Byrne. I think the answer is because we do not have the same aggressive interventionalists, we do not have that treatment arm at our hospital.
Dr John Chen (Honolulu, Hawaii). This is a very sick group of patients, and that is a quite an achievement to save their lives. We do not have a CAT scanner at the door, and therefore my question is as follows: Did you, in the course of your study, find any particular factors that would predict who these patients are?
Dr Byrne. There is a whole body of literature looking at people at risk for PE. If someone showed up with shortness of breath with or without chest pain who did not have other obvious causes, they got run through the CAT scan pretty quickly. There is a low threshold to consider it. It all has to do with thinking of the diagnosis and considering it and running them through the CAT scan.
Dr Chen. It sounds like at the Brigham they do not do a history and physical examination anymore. The CAT scan is the study of choice?
Dr Byrne. Well, you know, that emergency department. I try to go down there as little as possible because they might run me through the CAT scan. (laughter)
Dr Thor Sundt (Rochester, Minn). This is probably as much a comment as a question. Could you detail for us your technical approach to the right PA? I have found it particularly helpful to open the right PA behind the aorta, as one does for pulmonary thromboendarterectomy, and have taught the residents to do just that. I just wanted to highlight that technical point, which we believe is important to enable complete extraction of thrombus. I prefer this rather than trying to reach around a right-angle corner with a stone forceps from an incision in the main PA. Is this your practice?
Dr Byrne. Any time there is clot on the right side, we do that maneuver. It takes just a few minutes. I find it helpful, by the way, to stand on the left side of the table for these cases. I put on a head light, and I can see down that right PA beautifully. The left PA is of course going straight down, and you can see there, but the right PA would be very hard to—you would be putting your head in the field to try to look down the right PA, but from the left side of the table you can see it really well.
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