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J Thorac Cardiovasc Surg 2006;131:484-486
© 2006 The American Association for Thoracic Surgery
Brief Communication |
Department of Cardiothoracic Surgery, University of Wisconsin, Hospital and Clinics, Madison, Wis.
Received for publication June 16, 2005; accepted for publication August 8, 2005. * Address for reprints: Paramjeet S. Chopra, MD, University Hospital, Department of Cardiothoracic Surgery, 600 Highland Ave, Madison, WI 53792-3236 (Email: chopra{at}surgery.wisc.edu).
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Pulmonary embolism (PE) continues to be a significant cause of morbidity and mortality. It is estimated that nearly 200,000 to 300,000 PEs are diagnosed annually in the United States: approximately 1 per 1000 persons per year. Additionally, PE is associated with 50,000 to 100,000 deaths annually.
1
Operative intervention, although rarely performed, is indicated in patients with massive embolism resulting in hemodynamic instability. Massive embolism is defined as a PE associated with systolic pressures less than 90 mm Hg or a 40 mm Hg or greater decrease from baseline for longer than 15 minutes.
2
Patients with such embolic burden often rapidly progress to refractory hypotension and subsequent cardiopulmonary arrest. This patient population may benefit from surgical embolectomy.
Clinical Summary
We present a case of a 48-year-old black woman who presented with severe cerebral hemorrhage. She subsequently developed a pulmonary embolus and experienced worsening hypoxemia and a precipitous decrease in mean arterial pressure (>40 mm Hg). There was no identifiable septic or primary cardiac cause for this abrupt change. Echocardiographic evaluation showed signs of right heart strain and akinesis of the mid free right ventricular wall, with preserved apical motion (positive McConnell sign). Computed tomographic angiogram showed significant embolic burden, with a large saddle embolism (Figure 1). In view of the contraindications to thrombolytic/anticoagulation therapy, refractory hypotension despite maximal vasopressors, and worsening hypoxemia, urgent surgical embolectomy was considered.
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Comment
Currently, surgical pulmonary embolectomy is reserved only for patients who demonstrate profound cardiovascular collapse as a result of their embolic burden. Dating back to the early 1900s, sporadic case reports have documented attempts at open embolectomy. The earliest of these dates back to 1908, with Trendelenburg's classic description.
3
Pulmonary artery exposure was achieved via a T-shaped incision over the second costal margin immediately to the left of the sternum. A Sound was then passed around the aorta and pulmonary artery, the pulmonary artery was incised, and the clot was extracted with forceps and suction. It was not until 1924 that the first successful pulmonary embolectomy was performed by Kirschner,
4
Trendelenburg's assistant.
A review by Gibbon
5
in 1937 estimated that some 142 persons had undergone the Trendelenburg embolectomy, and only 9 had survived. Investigation into open cardiac repairs and the use of hypothermia was pioneered by Swan and colleagues
6
and Allison and associates
7
in the early 1950s and 1960s.
6,7
The modern equivalent has evolved from early studies in inflow occlusion and intra-arterial approaches to pulmonary valvotomy.
8-11
Profound cardiac and neurologic complications manifest if occlusion times increase past 3 minutes. Cooling blankets, hypothermia, and steroids have helped reduce these devastating complications, but profound postoperative deficits are still common.
Since the advent of cardiopulmonary bypass (CPB) in the early 1960s, most embolectomies have been performed with patients on pump. The first such operations were performed by Cooley and colleagues
12
in 1961 and Sharp
13
in 1962. CPB-assisted embolectomies have historically shown improved survival and significantly fewer postoperative neurologic morbidities.
Even in modern times, CPB is not always readily available; furthermore, there exists a discrete population in which the risks of CPB far outweigh the potential benefits of its use in embolectomy. It is in these clinical scenarios where inflow occlusion embolectomy provides a reasonable alternative to CPB-assisted embolectomy. With the judicious application of brief episodes of venous inflow stasis of up to 3 minutes, pulmonary embolectomy is perfectly feasible without the use of CPB. The limitation of this approach is clearly related to cerebral and systemic malperfusion; therefore, the procedure must be performed with a concerted effort and full awareness of its associated mortality and morbidity as a surgical salvage treatment when no other surgical option is available. We report this as another valuable tool in the surgeon's armamentarium when dealing with massive PE.
References
This article has been cited by other articles:
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  J. Singh, R. S. Dhaliwal, S. Biswal, and N. Swami Inflow occlusion in the era of modern cardiac surgery. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1246 - 1246. [Full Text] [PDF]
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