Surgical Pulmonary Embolectomy

Abstract

Pulmonary embolectomy is one of the oldest cardiac operations, dating back to the early 20th century. Initially performed blindly as a closed cardiac procedure, the operation is now performed on cardiopulmonary bypass with clots extracted from the opened pulmonary arteries under direct vision. Surgery was the mainstay of therapy for pulmonary emboli in the 1960s and 1970s. Presently, however, with the advent of effective nonsurgical therapy, pulmonary embolectomy is largely reserved for anatomically extensive central emboli with hemodynamic compromise or right ventricular strain, or for cases in which medical therapy has failed or is contraindicated. The results of surgery have improved greatly in recent years, with contemporary series reporting mortality rates below 10%. Patient selection and surgical management are the key to minimizing the mortality of this operation. If patients are operated on at an early stage, before the onset of irreversible right ventricular dysfunction or protracted cardiogenic shock, then the mortality risk is low. On the other hand, preoperative cardiac arrest leads to a fivefold increase in mortality. Modern intraoperative management includes cardiopulmonary bypass, avoidance of cardiac ischemia, extraction of clots under direct vision only, and placement of cava filters. Some patients are not suitable for pulmonary embolectomy, including those undergoing cardiopulmonary resuscitation, those with predominantly peripheral emboli, and patients who do not have immediate access to cardiac surgery (thrombolysis is preferable to a delay in treatment). On the other hand, in centers with the infrastructure for immediate embolectomy, surgery offers the fastest means of deobliterating the pulmonary arteries and should thus be considered as a therapeutic option in all patients with massive or even submassive pulmonary embolism.