PE surgery offers 'excellent' treatment option

18 August 2008

MedWire News: Surgery is an excellent treatment option for major pulmonary embolism (PE), offering good rates for both morbidity and mortality, Swiss researchers say.

"Even patients who present with cardiac arrest and require pre-operative cardiopulmonary resuscitation show satisfying results," say lead author Alexander Kadner and colleagues from the University Hospital Berne.

"Immediate surgical desobstruction favorably influences the pulmonary pressure and the recovery of right ventricular function, and remains the treatment of choice for patients with massive central and paracentral embolism with hemodynamic and respiratory compromise."

As reported in the Journal of Thoracic and Cardiovascular Surgery, 18 of the 25 PE patients assessed presented to the hospital in cardiogenic shock and eight developed cardiac arrest requiring cardiopulmonary resuscitation.

All patients underwent embolectomy under mild hypothermic cardiopulmonary bypass. None of the patients received inferior vena cava filters but eight patients underwent coronary artery bypass grafting, patent foramen ovale closure, ligation of a left atrial appendage, and/or removal of a right atrial thrombus.

Two patients died within 2 weeks of surgery due to intracerebral bleeding or multiorgan failure, giving a 30-day mortality rate of 8%, and two patients required further surgery for mediastinal bleeding, Kadner et al report.

Following-up the patients for a median of 2 years, the researchers calculated 1- and 4-year actuarial survival rates to be 80% and 76%, respectively. All four patient deaths were due to cancer.

Importantly, postoperative echocardiography showed that patients had achieved a significant reduction in pulmonary pressure, and at last follow-up, patients were within New York Heart Association class I or II with no further episodes of PE.

Noting that their findings contradict previous research, the researchers believe their success may be due to a multidisciplinary approach.

"Computed tomography helps to identify patients with centrally localized emboli, which are surgically accessible, whereas patients presenting with the majority of the clot burden located more peripherally might not be good candidates for a surgical intervention," they explain.

"Echocardiography allows the identification of patients with impending right ventricular dysfunction, which has been shown to be a strong risk factor for death."

J Thorac Cardiovasc Surg 2008; 136: 448-451