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Surgical Management of Acute Pulmonary Embolism

Neil Venardos, MD, Vicente Valero III, MD, Christopher Scott, MD, Jay D. Pal, MD, PhD
Surgical Management of Acute Pulmonary Embolism is a topic covered in the Adult and Pediatric Cardiac.

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Introduction

Pulmonary embolism (PE) is a pervasive clinical condition with an incidence of approximately 70 per 100,000 people, and it is estimated to account for more than 300,000 deaths annually in the United States.[1],[2] Current standard of care is to manage patients with “non-massive” PE with anticoagulation therapy alone for at least 6 months. Currently the American Heart Association (AHA) defines submassive PE as an acute PE with right ventricular dysfunction or myocardial necrosis but without systemic hypotension (systolic blood pressure is greater than 90 mm Hg).[3] About 80% of patients with acute PE present without systemic hypotension, and of this subset, about 25% to 55% will exhibit right ventricular dysfunction on echocardiogram.[4],[5],[6],[7] In contrast to submassive PE, patients with massive PE, as defined by the AHA, present with sustained hypotension, cardiac arrest, or profound bradycardia with signs of shock.[3]

Most pulmonary emboli will resolve with the use of systemic anticoagulation within 30 days.[8] The therapeutic strategy for submassive and massive PE is divided into pharmacologic, which includes heparin and thrombolytics, and mechanical, which involve catheter and surgical embolectomy. Most centers reserve surgical embolectomy (SE) for acute PE that has either failed catheter-based therapy, such as thrombolysis or mechanical extraction, or is otherwise contraindicated. Hence the role of the cardiothoracic surgeon in the care of these patients is limited to a relatively small subset of patients with acute pulmonary embolism. The complex decision-making involved in the care of these patients has driven many tertiary centers to build multidisciplinary acute PE teams comprised of critical care physicians, interventional radiologists, and a cardiothoracic surgeon to review complicated cases and develop a consensus care plan. These teams have shown improved outcomes after SE with appropriate patient selection.[9]

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Introduction

Pulmonary embolism (PE) is a pervasive clinical condition with an incidence of approximately 70 per 100,000 people, and it is estimated to account for more than 300,000 deaths annually in the United States.[1],[2] Current standard of care is to manage patients with “non-massive” PE with anticoagulation therapy alone for at least 6 months. Currently the American Heart Association (AHA) defines submassive PE as an acute PE with right ventricular dysfunction or myocardial necrosis but without systemic hypotension (systolic blood pressure is greater than 90 mm Hg).[3] About 80% of patients with acute PE present without systemic hypotension, and of this subset, about 25% to 55% will exhibit right ventricular dysfunction on echocardiogram.[4],[5],[6],[7] In contrast to submassive PE, patients with massive PE, as defined by the AHA, present with sustained hypotension, cardiac arrest, or profound bradycardia with signs of shock.[3]

Most pulmonary emboli will resolve with the use of systemic anticoagulation within 30 days.[8] The therapeutic strategy for submassive and massive PE is divided into pharmacologic, which includes heparin and thrombolytics, and mechanical, which involve catheter and surgical embolectomy. Most centers reserve surgical embolectomy (SE) for acute PE that has either failed catheter-based therapy, such as thrombolysis or mechanical extraction, or is otherwise contraindicated. Hence the role of the cardiothoracic surgeon in the care of these patients is limited to a relatively small subset of patients with acute pulmonary embolism. The complex decision-making involved in the care of these patients has driven many tertiary centers to build multidisciplinary acute PE teams comprised of critical care physicians, interventional radiologists, and a cardiothoracic surgeon to review complicated cases and develop a consensus care plan. These teams have shown improved outcomes after SE with appropriate patient selection.[9]

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Last updated: September 9, 2020