Pulmonary embolectomy in high-risk acute pulmonary embolism: The effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support

Abstract

ObjectivesTo investigate the effectiveness of a comprehensive therapeutic algorithm including extracorporeal life support (ECLS) in high-risk acute pulmonary embolism (aPE) treated with pulmonary embolectomy. Materials and methodsThis retrospective study included 25 consecutive patients of aPE treated with pulmonary embolectomy in a single institution between June 2005 and July 2012. All patients had high-risk aPE identified by computed tomographic angiography and were not suitable for thrombolytic therapy. High-risk aPE here was defined as aPE with (1) hemodynamic instability, (2) a pulmonary artery obstruction index (PAOI)≥0.5, (3) a diameter ratio of right ventricle-to-left ventricle (RV-to-LV)≥1.0, or (4) right heart thrombi. Once the eligibility was confirmed, a 3-staged therapeutic algorithm was adopted to perform an aggressive preoperative resuscitation, an expeditious pulmonary embolectomy with multidisciplinary postoperative care, and a thorough surveillance for recurrence. ResultsAmong the 25 patients, 24 had a PAOI≥0.5 and 23 had a RV-to-LV diameter ratio≥1.0. Four patients had right heart thrombi. Sixteen patients developed preoperative instability requiring inotropic and/or mechanical support. Eight in the 16 had a preoperative cardiac arrest (CA) and six of these were bridged to surgery on ECLS. Three in the 6 patients weaned ECLS after surgery and survived to discharge. The overall in-hospital mortality was 20% (n=5). A preoperative CA (Odds ratio [OR]: 16, 95% confidence interval [CI]: 1.4–185.4, p=0.027, c-index: 0.80) and a postoperative requirement of ECLS (OR: 36, 95% CI: 2.1–501.3, p=0.008, c-index: 0.85) was the pre- and postoperative predictor of in-hospital mortality. No late deaths or re-admission for recurrence were found during a median follow-up of 19 months (interquartile range: 8–29). ConclusionPulmonary embolectomy was an effective intervention of high-risk aPE. However, the occurrence of preoperative CA still carried a high mortality in spite of the assistance of ECLS.