Surgical therapy of fulminant pulmonary embolism: early and late results

Abstract

Background: Pulmonary embolectomy remains the only option for patients with fulminant pulmonary embolism and failure or contraindication of thrombolysis even today. Increasing prevalence of heparin-induced thrombocytopenia type II (HIT) adds a new significant problem, which was investigated in a retrospective study.

Methods: Between 1/1979 and 1/1998 41 patients (21 male; age: 51.1 +/- 14.8 years) with fulminant pulmonary embolism underwent pulmonary embolectomy under cardiopulmonary bypass: group I (1979-89): 31 patients; group II (1990-98): 10 patients. Group II included only patients who did not meet the criteria for acute thrombolysis, in 4 patients a HIT was preoperatively assured. All patients were in strongly compromised hemodynamic condition (33/41 high-dose catecholamines, 24/41 mechanical ventilation, 14/41 preoperative cardiopulmonary resuscitation).

Results: Perioperative mortality was 29% (group I: 9/31; group II: 3/10; n.s.) Preoperative resuscitation was the only predictive factor (with resuscitation: 9/14; without resuscitation: 3/27; p < 0.001). Severe but not fatal complications occurred in 11 patients: they fully recovered following treatment. Follow-up was completed to 93% (281 patient-years; mean: 10.6 years) and discovered 5 late deaths (late mortality: 1.7%/patient-year; 1 patient: bleeding due to anticoagulation; 4 patients: not related to operation). 26/28 (93%) patients were in NYHA functional class I or II. No recurrent pulmonary embolism or late clinical symptoms related to embolectomy were observed. There was no difference between group I and group II (including the 4 patients with HIT) regarding perioperative mortality, complication, and late results.

Conclusions: Pulmonary embolectomy on cardiopulmonary bypass remains an adequate therapy in patients with failure of or contraindication to thrombolysis, and HIT is not a contraindication.