Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association

Abstract

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism–related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

High-Risk Pulmonary Embolism: Management for the Intensivist

“…8,9 Novel approaches in treatment for high-risk PE including the use of percutaneous embolectomy, surgical embolectomy, and MCS may improve mortality and outcomes in this patient population. 5,10…”

“…Alternative treatment strategies include rapid percutaneous or surgical treatment options with concomitant MCS. 5,10 There are currently no randomized controlled trials looking at which type of reperfusion therapy, the timing of reperfusion therapy, or what combination of reperfusion therapies is superior for the management of the high-risk PE patient. Percutaneous treatment strategies for acute PE continue to evolve and currently present itself with a number of different device options available.…”

“…SPE is performed while a patient is on cardiopulmonary bypass, under general anesthesia, and is performed with induced cardiac arrest and aortic cross-clamping. 10 SPE has historically been reserved for patients who have failed other reperfusion therapies, have RHT, or have contraindications to certain therapies (eg, high bleed risk with ST). With the advancement of surgical techniques and perioperative practices, mortality with SPE has improved compared to historical SPE data.…”

“…With the advancement of surgical techniques and perioperative practices, mortality with SPE has improved compared to historical SPE data. 10 Although SPE is invasive, it allows for immediate removal of proximal thrombi and is associated with improvement in RV function. 10 Limitations to SPE include the need for an experienced surgical team and for general anesthesia, and it is more invasive compared to CDE.…”

“…10 Although SPE is invasive, it allows for immediate removal of proximal thrombi and is associated with improvement in RV function. 10 Limitations to SPE include the need for an experienced surgical team and for general anesthesia, and it is more invasive compared to CDE. Complications of SPE include bleeding complications, failure to wean from bypass, cardiac tamponade, pulmonary artery, injury and sternal wound infection.…”