Introduction: 80 years after Trendelenburg performed the first non-life saving operation for massive PE, this procedure seems to be neglected in the armamentarium of treatments for PE. The general knowledge on the mechanisms of thrombosis and the widespread use of perioperative low molecular weight heparins probably have lowered the incidence of massive PE. And with the advent of thrombolytic therapy surgery seems to be superfluous. However, some lifes can be saved by pulmonary embolectomy.
Material and methods: From November 1986 to May 2006, 40 patients underwent emergency embolectomy for massive PE or right heart emboli. The preoperative diagnosis was only clinical in 14 patients (35 %). In the other 26 diagnostic imaging was performed, with right heart thrombus in 11. Patients’ages ranged from 16 to 80 years (mean 51.5), with a majority of women (63 %). Eight (20 %) had received thrombolysis preoperatively. Fifteen (37 %) had cardiopulmonary resuscitation (CPR) prior to operation. Twenty eight patients had a contraindication to thrombylitic therapy of which recent surgery or trauma was identified in 24.
Results: All patients were operated with cardiopulmonary bypass (CPB), without cardiac arrest in 38 and with a mean aortic crossclamp time of 14.8 min (range 2 to 45) in 14 patients. Median CPB time was 87.5 min. Massive PE was removed in 32 (80 %). Thrombi limited to the right heart were detected in 6, and in 2 patients no thrombi could be detected after thrombolysis and CPR. Hospital mortality was 45 %. Of the patients receiving CPR, 12 of 15 (80 %) died. Of the 8 patients who received thrombolysis, 6 died postoperatively. Best survival was seen in patients with a contraindication to thrombolysis, who did not receive CPR (11/13, 85 %).
Conclusion: Acute pulmonary embolectomy can be life saving in massive PE with contraindication for thrombolysis, thrombi in the right heart or cardiogenic shock with the need for CPR.
Early referral of patients with hemodynamically important PE to an experienced cardiothoracic surgical centre should be considered when there is spontaneous circulation and when thrombolysis has not been or cannot be given.