Elsevier

International Journal of Cardiology

Volume 203, 15 January 2016, Pages 579-583
International Journal of Cardiology

Management of acute massive pulmonary embolism: Is surgical embolectomy inferior to thrombolysis?

https://doi.org/10.1016/j.ijcard.2015.10.223Get rights and content

Abstract

Background

Although current guidelines for pulmonary embolism (PE) treatment recommend surgical embolectomy when thrombolysis is contraindicated or has failed, their clinical outcomes rarely have been compared directly.

Methods

After excluding patients aged under 18 years and those with submassive or non-massive PE, 45 consecutive patients (median age, 68 years; 62% female; 31% experienced cardiac arrest before PE treatment onset; 33% had cancer diagnosis history; and 29% received extracorporeal membrane oxygenation [ECMO]) who underwent only thrombolysis (TL group; n = 19) or surgical embolectomy (SE group; n = 26, including 4 who had failed thrombolysis) for acute massive PE from 2000 to 2013 at Samsung Medical Center were enrolled to assess cardiac mortality as primary outcome.

Results

Median follow-up duration was 17.2 months. In the SE group, significantly higher proportions of patients had recent surgery and ECMO. Overall 30-day all-cause mortality rate was 24% (n = 11), without significant difference between the SE (15%) and TL (37%) groups (P = 0.098); however, cardiac mortality rate was significantly higher in the TL than SE group (Log rank P = 0.023). TL was an independent multivariate predictor of cardiac death (P = 0.03).

Conclusion

In this small retrospective single center experience, surgical embolectomy is associated with lower cardiac mortality risk than thrombolysis, which might render it first-line treatment option for acute massive PE for patients without life-limiting comorbidities.

Introduction

Massive pulmonary embolism (PE) is associated with hemodynamic instability [1], [2], with development of hypotension dramatically increasing expected mortality. The rapid reinstitution of sufficient pulmonary blood flow and right ventricular unloading therefore is important to save the patient's life. Although surgical embolectomy theoretically offers faster and more complete removal of thrombi in the major pulmonary arteries than systemic thrombolysis, surgical mortality is as high as 32% [3] and studies and guidelines therefore recommending it be reserved for patients with contraindications or who have failed to respond to systemic thrombolysis. However, surgical embolectomy is not a complicated procedure and its outcomes seem to be highly dependent on preoperative patient condition [3], [4]. The aim of this study therefore was to comparatively review clinical outcomes of acute massive PE management with surgical embolectomy or systemic thrombolysis.

Section snippets

Patients

From 2000 to 2013, 75 adult patients were diagnosed with massive PE at Samsung Medical Center. Of these 75 patients, 20 (27%) underwent neither surgical embolectomy nor systemic thrombolysis. Exclusion criteria for this study were age under 18 years, history of chronic PE, diagnosis of submassive or non-massive PE, and conservative management of PE, such as anticoagulation without thrombolysis or surgical embolectomy. The median follow-up duration was 17.2 (interquartile range, 53–74) months.

Patient characteristics and early outcomes

The median age was 68 years (interquatile range, 53–74). There were 28 (62%) female patients. The risk factors for acute PE were deep vein thrombosis in 20 (46%), malignancy in 15 (33%), major surgery within three months in 15 (33%), bedridden status in 6 (13%), and pregnancy in 4 (9%). Fifteen patients (33%) experienced cardiac arrest before definitive treatment (thrombolysis or surgical embolectomy). ECMO was used in 13 (29%) patients to manage cardiac arrest or refractory shock. Primary

Discussion

The pathogenesis of acute PE is severe occlusion of a major pulmonary artery by emboli. By definition, a patient with diagnosis of massive PE experiences cardiogenic shock [1]. Because of the high mortality of this diagnosis [6], [7], at least theoretically, prompt removal of emboli can save the life of a patient with acute massive PE. Although surgical embolectomy was thought to be effective, the high mortality of surgery prompted physicians to first consider less invasive management. Thus,

Conflict of interest

None of the authors have conflicts of interest to report.

Funding/support

This work was funded by Korea Healthcare Technology R&D Project, Ministry for Health, Welfare & Family Affairs, Republic of Korea (HI15C1087).

References (14)

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    They showed equivalent 30-day and long-term mortality from all causes between the groups; however, the thrombolysis group experienced more stroke (1.9% vs 0.8%; OR, 4.70; 95% CI, 1.08-20.42), need for reintervention (3.8% vs 1.2%; OR, 7.16; 95% CI, 2.17-23.62), and recurrence requiring hospitalization (7.9% vs 2.8%; HR, 3.38; 95% CI, 1.48-7.73), but a lower risk of major bleeding (3.6% vs 9.0%; OR, 0.53; 95% CI, 0.31-0.92), compared with the SE group. Smaller retrospective studies have made similar observations.36,37,41 Additionally, Aymard et al36 showed that patients who required rescue SE after failed thrombolysis achieved worse outcomes than those who received thrombolysis or embolectomy alone, indicating that attempted thrombolysis delayed definitive therapy, increased operative risks, or both for patients who ultimately required surgery.

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All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.

1

Drs. Y.H.C. and K.S. contributed equally to this work.

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