Acute pulmonary embolism with coexisting right heart thrombi in transit—surgical treatment of 20 consecutive patients

Abstract

OBJECTIVES The presence of right heart thrombi in transit in the setting of acute pulmonary embolism is associated with high mortality. The optimal management in such cases is inconclusive. We present the results of surgical treatment of 20 consecutive patients diagnosed with high or intermediate-high risk pulmonary embolism with coexisting right heart thrombi in transit. METHODS A retrospective analysis was performed of all consecutive patients undergoing surgical treatment in the Medicover Hospital between 2013 and 2021 for acute pulmonary embolism with coexisting thrombi in-transit in right heart cavities. The diagnosis was based on echocardiography, computed tomography pulmonary angiography, and laboratory tests. Eligibility criteria for surgical treatment were acute pulmonary embolism with right heart thrombi in transit, right ventricular overload on imaging studies, and significantly elevated levels of cardiac troponin and NTproBNP. All patients were operated on with extracorporeal circulation using deep hypothermia and total circulatory arrest. The primary end-point was hospital all-cause mortality; secondary end-points were perioperative complications and long-term mortality. RESULTS The analysis included 20 patients. There was no in-hospital death. Nearly one-third of patients required temporal hemofiltration for postoperative renal failure, but this did not involve the need for dialysis at discharge. No neurological complications occurred in any patient. The mean follow-up was 46 months (range 13–98). There was one death in the long-term follow-up, not related to pulmonary embolism. CONCLUSIONS Surgical treatment of patients with acute pulmonary embolism and coexisting right heart thrombi in transit can provide favourable results.

Role of catheter-directed therapies in the treatment of acute pulmonary embolism. Expert opinion of the Polish PERT Initiative, Working Group on Pulmonary Circulation, Association of Cardiovascular Interventions, and Association of Intensive Cardiac Care of the Polish Cardiac Society

“…In addition, the results depended on the experience of the center. In centers with extensive experience in performing surgical embolectomy, the total mortality rate was 4.2% to 6.6% (in patients without shock, 0%-3.6%; those in shock, 10.2%-12%; and those after cardiac arrest, 22%) [59,[64][65][66].…”

“…The advantage of surgical treatment of patients with acute PE is the ability to safely remove accompanying thrombus "in transit" in the right heart, especially thrombus trapped in the PFO [59]. ST or interventional treatment of PE carries the risk of thrombus traveling from the right heart into the pulmonary circulation, which, together with concomitant RV overload, can lead to cardiovascular collapse.…”

A Case Report of Under-Recognized Conditions in Pulmonary Embolism: Patent Foramen Ovale and Right Ventricular Thrombus

“…In patients with PE and coexisting RVT, reperfusion therapy is not associated with a reduced risk of PE-related mortality compared with no reperfusion therapy [18]. However, this evidence does not suggest that thrombolytic therapy for PE and coexisting RVT is safer than standard anticoagulant therapy [19]. Thus, in patients with concurrent PE and RVT, as in our case, it may be prudent to precannulate (e.g., a 4 Fr sheath) for ECMO prior to initiating anticoagulation therapy.…”

Treatment of high- and intermediate-high-risk pulmonary embolism by the Pulmonary Embolism Response Team: Focus on catheter-directed therapies

“…ST referred to the intravenous administration of recombinant tissue plasminogen activator (rtPA). SE was defined as the surgical removal of the pulmonary thrombi following the incision of pulmonary arteries under extracorporeal circulation, with aorta clamping and administration of cardioplegia [ 18 ]. CDTx included CDT, CDL, or a combination of both.…”