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J Thorac Cardiovasc Surg 2006;131:503-504
© 2006 The American Association for Thoracic Surgery
Letter to the Editor |
Department of Cardiothoracic Surgery, Royal Hospitals, Belfast, BT12 6BA, United Kingdom
We read with interest the study reported by Leacche and associates
1
regarding their surgical experience in treating massive pulmonary embolism. We would like to congratulate the authors for their excellent outcomes in this relatively large number of patients and for the encouraging results that they achieved with this patient population. The authors used a technique of cardiopulmonary bypass and temporary flow reductions for visualization of the pulmonary arterial tree for clot removal.
In the past 3 months we have treated 3 patients with massive pulmonary embolism by surgical embolectomy. The first was a 45-year-old patient who had rib fractures and subsequently deep vein thrombosis. The patient was admitted with shortness of breath and chest pain and had a cardiac arrest. After initial successful resuscitation, a pulmonary angiogram confirmed bilateral massive emboli in the pulmonary tree. A second 65-year-old patient had subdural and intracerebral hemorrhage from a fall down a stair while in an alcoholic stupor. This patient needed increasing inotropic and ventilatory support to maintain his oxygenation, and a subsequent computed tomographic scan of the chest revealed bilateral massive pulmonary emboli. A third 47-year-old patient with significant peripheral vascular disease was admitted with chest pain and shortness of breath. Massive pulmonary emboli were confirmed by computed tomographic scan. The first patient did not respond to thrombolysis, whereas the other 2 patients had documented right ventricular strain and dysfunction with paradoxical movement of the ventricular septum.
We performed surgical embolectomy under cardiopulmonary bypass with systemic cooling to 34°C with asystole induced by antegrade cold blood cardioplegia. This allowed excellent visualization of the branches of the pulmonary artery in a bloodless field. In the first 2 cases fresh embolus was easily extracted with a short crossclamp time (39 and 28 minutes) and cardiopulmonary bypass time (75 and 63 minutes). The third patient was found to have adherent organized thrombus. This was extremely difficult to remove but was extracted successfully due to good visualization with cardioplegic arrest (bypass time 107 minutes; crossclamp time 70 minutes).
We believe that cardioplegic arrest greatly facilitates the operation and obviates the need to reduce the flow to improve visualization. In a simple case of fresh thrombus, the time required is short and therefore is unlikely to have any detrimental effect on cardiac or immunologic function. In complicated cases, such as our third case with late presentation, the disadvantage of the longer ischemic time is easily balanced by the ability to successfully remove adherent clot without injury to the pulmonary artery.
Again, we would like to congratulate the authors for their exciting and encouraging results.
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