The surgical management of patients with massive pulmonary embolism (MPE) and high-risk submassive PE (SMPE) was found to be safe and highly effective for achieving right ventricular (RV) recovery, researchers reported in the Journal of the American College of Cardiology.
In this study, surgical embolectomy and/or venoarterial extracorporeal membrane oxygenation (ECMO) were compared for the treatment of MPE vs SMPE. RV recovery was defined by the improvement of central venous pressure, pulmonary artery systolic pressure, right ventricular/left ventricular ratio, and right ventricular fractional area change.
A total of 136 patients (mean age, 57.7 ± 14.7; 58.1% men) with PE (SMPE, n=92; MPE, n=44) who underwent treatment between 2005 and 2019 were included. The MPE and SMPE groups were largely similar regarding demographics, except for a greater percentage of patients with MPE vs SMPE who were African American (38.6% vs 21.7%, respectively). Patients with MPE vs SMPE more frequently had syncope (59.1% vs 25.0%, respectively; P =.0003), Glasgow Coma Scale score ≤4 (22.7% vs 0%, respectively), and failed thrombolysis (18.2% vs 4.3%, respectively; P =.008).
Embolectomy was the most common primary treatment modality (86.0%), and it was more prevalent in patients with SMPE (98.9%) than in those with MPE (59.1%). None of the patients with SMPE who were treated with primary embolectomy required postoperative ECMO, compared with 6.8% of patients with MPE who needed postoperative ECMO, all of whom received preoperative cardiopulmonary resuscitation.
Right ventricular function improved, as assessed by improvements in central venous pressure (from 23.4±4.9 mm Hg to 10.5±3.1 mm Hg), pulmonary artery systolic pressure (from 60.6±14.2 mm Hg to 33.8±10.7 mm Hg), right ventricular/left ventricular ratio (from 1.19±0.33 to 0.87±0.23; P < 005), and fractional area change (from 26.8 to 41.0; P <.005).
Overall mortality was 4.4% (SMPE, 1.1%; MPE, 11.6%), and none of the deaths was secondary to RV failure. Morbidity and mortality were highly associated with preoperative cardiopulmonary resuscitation, according to a subgroup analysis.
Study limitations include its retrospective nature, and the lack of a control group (eg, treated nonsurgically or with an alternative therapy).
“Although various association and society guidelines either do not mention the use of embolectomy or ECMO or relegate their use to strictly salvage situations, our data add to a growing body of research suggesting that modern surgical outcomes warrant consideration of these therapies for patients with MPE and high-risk SMPE,” noted the study authors.
Goldberg JB, Spevack DM, Ahsan S, et al. Survival and right ventricular function after surgical management of acute pulmonary embolism. J Am Coll Cardiol. 2020;76:903-11.