Acute Pulmonary Embolism

Author: Dawn S. Hui, MD
Institution: Saint Louis University
Date Reviewed: March 2014
Learning Domain: Adult Cardiac Surgery
Learning Objective: Acute Pulmonary Embolism
PowerPoint File: Acute Pulmonary Embolism

 

Discussion Points for Conference

  • What made Dx of PE clear in this case?
  • Initial Diagnostic criteria to make Dx
    • Sensitivity / Specificity / Accuracy
  • Initial Therapeutic Options
    • Heparin
    • Thrombolytics
    • Catheter based embolectomy
    • Surgery
  • Why surgery in this case?

 

Treatment Options

  • Anticoagulation with heparin alone
  • Catheter-directed thrombolysis vs pharmacomechanical thrombolysis    
    • Thrombus fragmentation
    • Rheolytic thrombectomy
    • Suction thrombectomy
    • Rotational thrombectomy 
  • Surgical embolectomy

 

Surgical Options

  • On-pump beating vs arrest vs DHCA
  • Clot removal: Randall Stone forceps, Fogarty catheters, manual compression of lungs
  • Retrograde flushing via PV cannulation described 
    • (Kadner  et al.  Excellent outcome after surgical treatment of massive pulmonary embolism in critically ill patients. JTCVS 2008 Aug; 136: 448-51)
  • Inflow occlusion pulmonary embolectomy for extremely poor-risk patients

 

Outcomes of Surgical Embolectomy

  • Contemporary series 
    • 20-32%
  • Higher with pre-op cardiac arrest (massive PE)
    • 59% vs 29%
  • Higher after 2nd course of failed thrombolytics
    •  38% vs 7%
  • Indications for surgical pulmonary     embolectomy  may be expanding for: 
    • Submassive PE: mortality 6 - 8%
    • Paradoxical embolism

 

Trend towards surgery/thrombolytics

  • Rationales: 
    • Better morbidity/mortality outcomes with hemodynamic stability
    • Improve RV function acutely
    • Decrease long-term risk of pulmonary hypertension (selected case series for surgery, MOPETT trial for thrombolytics)
  • Controversies – risk/benefit?
    • Added risk of bleeding even without traditional contraindications
    • Little data to support survival improvement

 

Learning Points

  • Embolectomy for acute PE traditionally performed for patients in extremis with high morbidity, mortality
  • Trend towards expanding indications for surgery and thrombolysis for submassive PE (not in current indications)
    • Focus on restoring RV function
    • Focus on long-term pulmonary hypertension (MOPETT trial)
  • Decision-making is a multidisciplinary process and needs to consider bleeding risks; CT surgeon may be called upon to make  some management decisions