Discussion:
Pulmonary embolism is a major cause of cardiovascular
mortality.3 Most clinical guidelines only recommend
surgical embolectomy for massive PE and only when thrombolysis has
failed, is contraindicated, or for patients presenting in extremis with
cardiopulmonary collapse.1,4 Emerging data from our
institution and others support the extended utility of surgical
embolectomy for treatment of massive PE. As we previously wrote, recent
reports highlighting improved surgical techniques have shown that
surgical pulmonary embolectomy yields similar 30-day and 5-year
mortality rates compared to thrombolytic therapy. 5,6However, compared to thrombolysis, surgical pulmonary embolectomy was
associated with lower rates of bleeding complications, stroke, and
requirement for re-intervention within 30 days.6
Our introduction of the MIPE via a left mini thoracotomy highlights an
advancement in surgical embolectomy in that it avoids sternotomy and
related complications allowing for enhanced recovery. With continued
experience with the MIPE we offer the following as important lessons
learned after our initial description1.
- Location of the anterior thoracotomy should be based on pre-operative
axial and sagittal imaging rather than adhering to a standardized
third interspace. In the case presented the 3rdintercostal space was too inferior and created difficulty with
exposure and visualization of the PA. The subsequent MIPE procedures
done at our institution have been performed via the
2nd intercostal space with improved exposure and
ease of surgery.
- Appropriate venous drainage of the heart is important to successfully
complete the operation. In the case presented, the single venous
drainage catheter placed from the femoral vein going up into the right
atrium may have slipped back into the IVC during surgery, or was not
capable of sufficient drainage in the large patient, or combination of
both factors, thus causing the right ventricle to not adequately
decompress and forced us to rely on robust suctioning within the
pulmonary arteriotomy to successfully complete the case. We now employ
dual venous drainage (placed via the common femoral vein into the RA
and the internal jugular vein into the SVC-RA junction) to ensure
proper venous drainage which allowed for improved visualization and
clot extraction.
- Closure of the pulmonary arteriotomy can be much more easily
facilitated by placement of a purse-string suture about the planned
arteriotomy prior to incision. We intend to employ this technique,
here forward, for PA closure.
- Early utilization of Aerosolized Epoprostenol is an important adjunct
to aid the recovering right ventricle.
- Care of patients with massive pulmonary embolism requires a team
based, multi-disciplinary approach. The care of this patient involved
consulting services including vascular surgery, hematology,
nephrology, physical therapy and social work services.
- While we have demonstrated a low rate of complications, and zero
mortality from this procedure in our previous
report1, the case presented highlights that while we
were able to perform the MIPE, complications did still occur
(prolonged ventilatory and inotropic support to aid the recovering
right heart, AKI, HIT) and are to be expected with any patient who
requires surgery for pulmonary embolus due to the inherent risk of
cardiopulmonary bypass. Even so, we believe that recovery from the
small mini anterior thoracotomy as described compared to a standard
sternotomy may be easier and simpler for patients.
In summary, we have detailed several augmentations to our original
description of the MIPE.1 We believe the operation and
results are reproducible and can be a valuable tool in the armamentarium
of the cardiothoracic surgeon.
References:
1. Fallon J, Luvika G, Zapata D, Lattouf O. Initial Experience with
Non-Sternotomy Minimally Invasive Pulmonary Embolectomy with
Thoracoscopic Assistance. Innovations 2020, Vol. 15(2) 180–184
2. Fallon J. Minimally Invasive Pulmonary Embolectomy With Thoracoscopic
Assistance. doi:10.25373/CTSNET.11964948
3. Bĕlohlávek J, Dytrych V, Linhart A. Pulmonary embolism, part I:
Epidemiology, risk factors and risk stratification, pathophysiology,
clinical presentation, diagnosis and nonthrombotic pulmonary embolism.Exp Clin Cardiol . 2013;18(2):129-138.
http://www.ncbi.nlm.nih.gov/pubmed/23940438. Accessed March 8, 2020.
4. Konstantinides S V., Torbicki A, Agnelli G, et al. 2014 ESC
Guidelines on the diagnosis and management of acute pulmonary embolism.Eur Heart J . 2014;35(43):3033-3080. doi:10.1093/eurheartj/ehu283
5. Aymard T, Kadner A, Widmer A, et al. Massive pulmonary embolism:
surgical embolectomy versus thrombolytic therapy–should surgical
indications be revisited? Eur J Cardiothorac Surg .
2013;43(1):90-94; discussion 94. doi:10.1093/ejcts/ezs123
6. Lee T, Itagaki S, Chiang YP, Egorova NN, Adams DH, Chikwe J. Survival
and recurrence after acute pulmonary embolism treated with pulmonary
embolectomy or thrombolysis in New York State, 1999 to 2013. J
Thorac Cardiovasc Surg . 2018;155(3):1084-1090.e12.
doi:10.1016/j.jtcvs.2017.07.074
Image 1: Computed tomography showing: (A) saddle pulmonary embolus (B)
right ventricle strain with right ventricular size larger than left
ventricle in diastolic phase.