Residual pulmonary hypertension after retrograde pulmonary embolectomy: long-term follow-up of 30 patients with massive and submassive pulmonary embolism

Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

Surgical Management of Acute and Chronic Pulmonary Embolism

Surgical pulmonary embolectomy and pulmonary thromboendarterectomy are well-established treatment strategies for patients with acute and chronic pulmonary embolism, respectively. For both procedures, techniques and outcomes have evolved considerably over the past decades. Patients with massive and submassive acute pulmonary embolism are at risk for rapid decline owing to right ventricular failure and shock. When thrombus is proximal, embolectomy can rapidly restore cardiac function. Chronic thromboembolic pulmonary hypertension is a more complex disease that requires skilled, careful dissection of the arterial wall, including vascular intima. When successful, surgery leads to clinical cure of the associated pulmonary hypertension, with excellent long-term outcomes.

Critical Care of Patients After Pulmonary Thromboendarterectomy

Pulmonary thromboendarterectomy (PTE) remains the only curative surgery for patients with chronic thromboembolic pulmonary hypertension (CTEPH). Postoperative intensive care unit care challenges providers with unique disease physiology, operative sequelae, and the potential for detrimental complications. Central concerns in patients with CTEPH immediately after PTE relate to neurologic, pulmonary, hemodynamic, and hematologic aspects. Institutional experience in critical care for the CTEPH population, a multidisciplinary team approach, patient risk assessment, and integration of current concepts in critical care determine outcomes after PTE surgery. In this review, the authors will focus on specific aspects unique to this population, with integration of current available evidence and future directions. The goal of this review is to provide the cardiac anesthesiologist and intensivist with a comprehensive understanding of postoperative physiology, potential complications, and contemporary intensive care unit management immediately after pulmonary endarterectomy.

Incidence and risk factors of chronic thromboembolic pulmonary hypertension in patients after acute pulmonary embolism

BACKGROUND

Early identification and treatment of chronic thromboembolic pulmonary hypertension (CTEPH) are critical to prevent disease progression. We determined the incidence and risk factors for CTEPH in patients with a first episode of acute pulmonary embolism (PE).

METHODS

In this study, consecutive patients with first-episode acute PE were followed for ≤5 years. Pulmonary hypertension (PH) was screened for by echocardiography. Suspected cases were evaluated by right heart catheterization (RHC) and pulmonary angiography (PA). If invasive procedures were not permitted, PH was diagnosed by systolic pulmonary artery pressure (SPAP) >50 mmHg. Diagnosis of CTEPH was confirmed by PA, ventilation/perfusion (V/Q) lung scan, or computed tomography (CT) PA (CTPA).

RESULTS

Overall, 614 patients with acute PE were included (median follow-up, 3.3 years). Ten patients were diagnosed with CTEPH: cumulative incidence 0.8% [95% confidence interval (CI), 0.0-1.6%] at 1 year, 1.3% (95% CI, 0.3-2.3%) at 2 years, and 1.7% (95% CI, 0.7-2.7%) at 3 years. No cases of CTEPH developed after 3 years. History of lower-limb varicose veins [hazard ratio (HR), 4.3; 95% CI, 1.2-15.4; P=0.024], SPAP >50 mmHg at initial PE episode (HR, 23.5; 95% CI, 2.7-207.6; P=0.005), intermediate-risk PE (HR, 1.2; 95% CI, 1.0-1.4; P=0.030), and CT obstruction index over 30% at 3 months after acute PE (HR, 42.5; 95% CI, 4.4-409.8; P=0.001) were associated with increased risk of CTEPH.

CONCLUSIONS

CTEPH was not rare after acute PE in this Chinese population, especially within 3 years of diagnosis. Lower-limb varicose veins, intermediate-risk PE with elevated SPAP in the acute phase, and residual emboli during follow-up might increase the risk of CTEPH.

Surgical embolectomy for acute massive pulmonary embolism

OBJECTIVE

Acute massive pulmonary embolism (PE) is associated with significant mortality rate despite diagnostic and therapeutic advances. The aim of this study was to analyze our clinical outcomes of patients with acute massive PE who underwent emergency surgical pulmonary embolectomy.

METHODS

This retrospective study included 13 consecutive patients undergoing emergency surgical pulmonary embolectomy for acute massive PE at our institution from March 2000 to November 2013. The medical records of all patients were reviewed for demograhic and preoperative data and postoperative outcomes. All patients presented with cardiogenic shock with severe right ventricular dysfunction confirmed by echocardiography, where 4 (30.8%) of the patients experienced cardiac arrest requiring cardiopulmonary resuscitation before surgery.

RESULTS

The mean age of patients was 61.8 ± 14 years (range, 38 to 82 years) with 8 (61.5%) males. The most common risk factors for PE was the history of prior deep venous thrombosis (n = 9, 69.2%). There were 3 (23.1%) in-hospital deaths including operative mortality of 7.7% (n = 1). Ten (76.9%) patients survived and were discharged from the hospital. The mean follow-up was 25 months; follow-up was 100% complete in surviving patients. There was one case (7.7%) of late death 12 months after surgery due to renal carcinoma. Postoperative echocardiographic pressure measurements demonstrated a significant reduction (P < 0.001). At final follow-up, all patients were in New York Heart Association class I and no readmission for a recurrent of PE was observed.

CONCLUSION

Surgical pulmonary embolectomy is a reasonable option and could be performed with acceptable results, if it is performed early in patients with acute massive PE who have not reached the profound cardiogenic shock or cardiac arrest.