Survival and Right Ventricular Function After Surgical Management of Acute Pulmonary Embolism

J Am Coll Cardiol. 2020 Aug 25;76(8):903-911. doi: 10.1016/j.jacc.2020.06.065.

Abstract

Background: Acute pulmonary embolism (PE) is associated with high morbidity and mortality because of right ventricular (RV) failure. There is evidence suggesting surgical therapy (surgical embolectomy or venoarterial extracorporeal membrane oxygenation [ECMO]) is safe and effective.

Objectives: The aim of this study was to assess the safety and efficacy of surgical management of acute PE.

Methods: Surgical embolectomy and/or venoarterial ECMO were compared, between 2005 and 2019, for massive PE (MPE) versus high-risk submassive PE (SMPE). RV recovery was defined as improvements in central venous pressure, pulmonary artery systolic pressure, RV/left ventricular ratio, and RV fractional area change.

Results: One hundred thirty-six patients with PE (92 with SMPE and 44 with MPE) were identified. Patients with MPE more often presented with syncope (59.1% [26 of 44] vs. 25.0% [23 of 92]; p = 0.0003), Glasgow Coma Scale score ≤4 (22.7% [10 of 44] vs. 0% [0 of 92]), and failed thrombolysis (18.2% [8 of 44] vs. 4.3% [3 of 92]; p = 0.008). Pre-operative cardiopulmonary resuscitation occurred in 43.2% of patients with MPE (19 of 44). Most patients with SMPE were treated with embolectomy (98.9% [91 of 92]), while ECMO was used more in those with MPE (ECMO in 40.9% [18 of 44], embolectomy in 59.1% [26 of 44]). RV function improved as measured by central venous pressure (from 23.4 ± 4.9 to 10.5 ± 3.1 mm Hg), pulmonary artery systolic pressure (from 60.6 ± 14.2 to 33.8 ± 10.7 mm Hg), RV/left ventricular ratio (from 1.19 ± 0.33 to 0.87 ± 0.23; p < 0.005), and fractional area change (from 26.8 to 41.0; p < 0.005). Mortality was 4.4% (6 of 136; SMPE, 1.1% [1 of 92]; MPE, 11.6% [5 of 44]). Subgroup analysis showed morbidity and mortality were highly associated with pre-operative cardiopulmonary resuscitation.

Conclusions: Surgical management of patients with MPE and high-risk SMPE is safe and highly effective at achieving RV recovery.

Keywords: CPR; extracorporeal membrane oxygenation; outcomes; pulmonary embolism; right ventricular failure.

MeSH terms

  • Acute Disease
  • Embolectomy* / adverse effects
  • Embolectomy* / methods
  • Extracorporeal Membrane Oxygenation* / adverse effects
  • Extracorporeal Membrane Oxygenation* / methods
  • Female
  • Heart Function Tests / methods
  • Heart Function Tests / statistics & numerical data
  • Humans
  • Male
  • Middle Aged
  • Outcome Assessment, Health Care
  • Patient Selection
  • Pulmonary Embolism* / complications
  • Pulmonary Embolism* / physiopathology
  • Pulmonary Embolism* / surgery
  • Recovery of Function
  • Risk Adjustment / methods*
  • Risk Factors
  • Severity of Illness Index
  • Ventricular Dysfunction, Right* / diagnosis
  • Ventricular Dysfunction, Right* / etiology
  • Ventricular Dysfunction, Right* / physiopathology