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Ann Thorac Surg 1997;63:1584-1586
© 1997 The Society of Thoracic Surgeons

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Original Article: General Thoracic

Emergency Pulmonary Embolectomy With Percutaneous Cardiopulmonary Bypass

Department of Cardiovascular Surgery, Saga Prefecture Hospital "Koseikan," Saga, Japan

Accepted for publication December 21, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Background. The management of patients with acute pulmonary embolism remains difficult, particularly when cardiogenic shock is involved. The preoperative incidence of cardiac arrest compromises the results of emergency pulmonary embolectomy. In an attempt to reduce the operative mortality rate, we applied percutaneous cardiopulmonary bypass support to restore vital organ perfusion before the surgical intervention.

Methods. Percutaneous cardiopulmonary bypass support was preoperatively instituted in 3 patients with acute cardiopulmonary collapse caused by massive pulmonary embolism. In each patient, cardiac massage and endotracheal intubation were necessary due to loss of consciousness, hypotension, and severe cyanosis. Transesophageal echocardiography was performed to detect any evidence of thrombus in the main pulmonary artery, and each patient underwent the emergency pulmonary embolectomy using conventional cardiopulmonary bypass through a median sternotomy.

Results. Percutaneous cardiopulmonary bypass support immediately provided effective cardiopulmonary resuscitation. Transesophageal echocardiography clearly demonstrated any evidence of thrombus located in the pulmonary artery. Each patient was discharged from the hospital without any postoperative complication.

Conclusions. The use of percutaneous cardiopulmonary bypass support immediately resuscitated and stabilized the cardiopulmonary function and allowed for successful emergency pulmonary embolectomy. In each patient, transesophageal echocardiography was useful for prompt and noninvasive diagnosis.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Pulmonary embolism has been increasingly recognized as a factor responsible for in-hospital death. The incidence of embolism in all actuality is probably low. Conservative anticoagulation therapy is effective for most patients [1]. In the rest of the patients, anticoagulation therapy alone is insufficient or even contraindicated. Some of these patients unresponsive to the usual measures of cardiopulmonary resuscitation are reasonable candidates for pulmonary embolectomy, as this may represent their only chance for survival [2, 3]. This report reviews our current results of emergency pulmonary embolectomy using percutaneous cardiopulmonary bypass support (PCPS) and describes the beneficial use of transesophageal echocardiography (TEE) in prompt, accurate diagnosis.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
From January 1991 to September 1995, 3 patients underwent emergency pulmonary embolectomy (Table 1). There were 1 man and 2 women aged 55, 37, and 76 years, respectively. Two patients were recovering from surgical procedures and the other had been receiving treatment for lower limb paralysis of unknown cause. In the event, all patients required temporary external cardiac massage. Two patients were in cardiac arrest; the other was in sinus bradicardia with severe hypotension. Each patient remained hypoxic despite an inspired oxygen fraction of 1.0 with endotracheal intubation. A transthoratic echocardiogram demonstrated marked dilation of the right ventricle and the small left ventricle. Acute pulmonary embolus was strongly suspected, and PCPS was initiated for cardiopulmonary resuscitation. A short (11 cm) 16F cannula was used for arterial cannulation, whereas a long (50 cm) 20F cannula was used for venous cannulation. Cannulation and setting up a pump circuit took approximately 15 minutes in each case. After institution of PCPS, the 2 patients recovered consciousness, whereas the other 1 was drowsy. The hemodynamic condition was stabilized after institution of PCPS. Time from institution of PCPS to operation in each patient was 129, 105, and 100 minutes, respectively.

View larger version (89K): [in this window] [in a new window]   Fig 1. . Thrombus detected by transesophageal echocardiography. (ASCEND. = ascending; PA = pulmonary artery; RT = right; S-G CATH. = Swan-Ganz catheter.)

View larger version (171K): [in this window] [in a new window]   Fig 2. . Thrombus detected by transbronchial echocardiography. (Rt-PA = right pulmonary artery; SVC = superior vena cava.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Massive pulmonary embolization remains one of the intractable diseases leading to acute cardiogenic shock associated with severe cyanosis. In such events, conventional cardiopulmonary resuscitation including cardiac massage is usually not effective due to right ventricular outflow obstruction. Prompt and appropriate surgical intervention using pulmonary embolectomy is needed to prevent sudden death. Although surgical pulmonary embolectomy is widely recognized, the result is not satisfactory because the patients are generally compromised and preoperatively at high risk of hemodynamic and respiratory deterioration. Meyer and associates [4] reported that the mortality rate of emergency pulmonary embolectomy for patients after a preoperative cardiac arrest was 58%. It has been reported that preoperative cardiac arrest and cardiogenic shock were independent incremental risk factors in the treatment of emergency pulmonary embolectomy [4, 5]. To improve the results of emergent pulmonary embolectomy, quick diagnosis and hemodynamic stabilization are crucial in the preoperative period.

In our study, 2 patients were in cardiac arrest and the other was in severe hypotension, and all required cardiopulmonary resuscitation. Our experience suggested that the institution of PCPS permits prompt and effective hemodynamic stabilization. Also, PCPS drastically improves oxygenation. In addition, PCPS allows time to transfer patients uneventfully to the operating room. Phillips and colleagues [6] reported their initial experience of PCPS for refractory cardiac arrest in 1983. Percutaneous cardiopulmonary bypass support is now widely employed for coronary angioplasty or valvuloplasty with favorable results [7, 8]. Our findings suggest that cardiogenic shock associated with massive pulmonary embolism can also be one of the recommended applications of PCPS.

The use of TEE helps to promptly determine an accurate diagnosis in an emergency setting. Goldhaber [1] has pointed out 12 clinical signs in acute right heart failure that are suggestive of a pulmonary embolism. These signs may not be present or, if present, they may be misleading. The common transthoracic echocardiographic findings of pulmonary embolism are marked dilatation in the right ventricle and a normal or relatively small left ventricle. When the hemodynamics are stable, a pulmonary arteriogram can be employed for a definite diagnosis. In some instances, however, the degree of compromise is so severe that an immediate move to the operating unit is indicated. In such circumstances, TEE is effective for a diagnosis of pulmonary embolism, and the thrombus can be visualized in the main pulmonary artery in many cases.

The area of the pulmonary artery that can be visualized on TEE is limited because of the trachea. As an additional measure, we therefore attempted tracheobroncheal echocardiography using a small-calibered TEE probe. A TEE probe 5.0 mm in diameter (UST-5240, 5 MHz; Aloka, Tokyo, Japan) was inserted through an intubation tube. Anatomically, the trachea and bronchus are positioned behind the pulmonary artery. Thrombus could then be seen clearly with the probe with no technical difficulty. Application of both tracheobroncheal echocardiography and TEE covers an extensive area to detect thrombus in the pulmonary artery. We recommend tracheobroncheal echocardiography for intubated patients.

In conclusion, we report here our current experience of emergency pulmonary embolectomy for massive pulmonary embolism. The use of PCPS allows time until the operation by resuscitating deteriorated cardiopulmonary function. The application of TEE helps the surgeon make a prompt diagnosis and clarify the location of thrombus noninvasively.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Comment References

 
Address reprint requests to Dr Ohteki, Department of Cardiovascular Surgery, Saga Prefecture Hospital "Koseikan," 1-12-1 Mizugae, Saga City, Saga 840, Japan.

	References

Top Footnotes Abstract Introduction Patients and Methods Comment References

 

1. Goldhaber SZ. Thrombolysis for pulmonary embolism. Prog Cardiovasc Dis 1991;34:113–34.[Medline]
2. Glassford DM Jr, Alford WC Jr, Burrus GR, Stoney WS, Thomas CS Jr. Pulmonary embolectomy. Ann Thorac Surg 1981;32:28–32.[Abstract]
3. Robison RJ, Fehrenbacher J, Brown JW, Madura JA, King H. Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus. Ann Thorac Surg 1986;42:52–5.[Abstract]
4. Meyer G, Tamisier D, Sors H, et al. Pulmonary embolectomy: a 20-year experience at one center. Ann Thorac Surg 1991;51:232–6.[Abstract]
5. Stulz P, Schlapfer R, Feer R, Habicht J, Gradel E. Decision making in the surgical treatment of massive pulmonary embolism. Eur J Cardiothorac Surg 1994;8:188–93.[Abstract]
6. Phillips SJ, Ballentine B, Slonine D, et al. Percutaneous initiation of cardiopulmonary bypass. Ann Thorac Surg 1983;36:223–5.[Abstract]
7. Vogel RA, Tommaso CL, Gundry SR. Initial experience with coronary angioplasty and aortic valvuloplasty using elective semipercutaneous cardiopulmonary support. Am J Cardiol 1988;62:811–3.[Medline]
8. Vogel RA. The Maryland experience: angioplasty and valvuloplasty using percutaneous cardiopulmonary support. Am J Cardiol 1988;62:11K–4K.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Ohteki, H. Articles by Narita, Y. Search for Related Content PubMed PubMed Citation Articles by Ohteki, H. Articles by Narita, Y.