Care of Patients With Pulmonary DisordersSurgical embolectomy versus thrombolytic therapy in the management of acute massive pulmonary embolism: Short and long-term prognosis
Introduction
Acute massive pulmonary embolism (AMPE) is life-threatening. Despite advances in diagnosis and therapy, AMPE is still associated with exceptionally high mortality and morbidity rates.1, 2 Patients presenting with AMPE are at high risk of circulatory collapse, medical and mechanical reanimation and late pulmonary hypertension.3
Prompt treatment should be undertaken when dealing with AMPE. However, optimal management remains debated, and there is no consensus regarding the best therapeutic method. Although in recent studies the results of surgical embolectomy have been satisfying, current guidelines suggest thrombolytic therapy as the treatment of choice. Therefore surgical management is placed in reserve for critically ill and high-risk patients, in whom thrombolysis is absolutely contraindicated or has failed.4 Few studies have been conducted on short and long-term consequences of surgical embolectomy and thrombolysis. The rare incidence of acute massive pulmonary embolism and difficulty in matching patients has limited research on this issue. The present study aimed to analyze the short and long-term results in patients suffering from AMPE treated with either surgical embolectomy or thrombolytic therapy over an 8-year period.
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Methods
A non-randomized prospective study was designed on patients referred with acute massive unilateral or bilateral pulmonary embolism. A number of parameters including early mortality, SPAP, RVD and bleeding complications were recorded during hospitalization. Thereafter, late mortality, SPAP, RVD and New York Heart Association (NYHA) class of patients were assessed during follow-up.
Demographic and baseline characteristics
From May 2004 to November 2012, 120 consecutive patients with diagnosis of AMPE were enrolled, of whom 78 underwent TT, 30 underwent SE and 12 were excluded due to the lack of accessibility or refusal of intervention. Seventeen patients underwent rescue surgery due to failed TT. The clinical characteristics of patients at hospital admission are shown in Table 1. Indications for surgery were contraindication for thrombolysis in 9 patients (30.0%), cardiopulmonary arrest in 12 patients (40.0%),
Discussion
There are several guidelines regarding the management of pulmonary embolism. Despite improvement in diagnosis and treatment strategies, the morbidity and mortality attributable to AMPE remain high. Management of AMPE is one of the most controversial topics in emergency medicine. The three major therapeutic options for management of AMPE are open surgical embolectomy, thrombolysis and catheter embolectomy, each having limitations and complications.6, 9, 10 Our study was designed to compare the
Conclusion
With the improvement of surgical techniques, surgical embolectomy can be the most effective treatment for AMPE in eligible patients. Patients who underwent open pulmonary embolectomy had better RVD, SPAP and NYHA functional class and did not have bleeding complications. A comparison with thrombolysis shows a better survival for surgery, however, this did not reach statistical significance. In contrast, patients who underwent SE after thrombolytic therapy failure clearly demonstrate a critically
Acknowledgments
We would like to thank the staff at Echocardiography and Cardiac emergency ward of Ghaem Hospital. Special thanks are due to Professor Fazlinezhad for her expert assistance in echocardiography.
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Conflict of interest: None declared.