Emergency Surgical Embolectomy for Pulmonary Emboli After Failed Thrombolysis
Sharon HL Chu, MBBS,
David Andrews, FRACS,
Yuki Watanabe, MBBS
Department of Cardiothoracic Surgery, Royal Perth Hospital, Perth, Western Australia
Sharon HL Chu, MBBS, Tel: +61 8 9224 2244 Fax: +61 8 9224 1977 Email: sharonchu{at}gmail.com, Department of Cardiothoracic Surgery, Royal Perth Hospital, GPO Box X2213, Perth, Western Australia.
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ABSTRACT
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A 34-year-old man presented in cardiogenic shock secondary to massive pulmonary embolism. Surgical embolectomy was performed after failed thrombolysis. Intraoperatively, a right atrial lesion and pulmonary emboli were removed. Histopathology revealed myxoma complicated by pulmonary emboli. The patient made a good recovery. This case suggests that surgical embolectomy should be considered as first-line treatment for all patients with acute massive pulmonary embolism, and not reserved for those with severe hemodynamic compromise or failed conservative management.
Key Words: Embolectomy • Myxoma • Pulmonary Embolism • Thrombolytic Therapy
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INTRODUCTION
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Surgical pulmonary embolectomy has traditionally been reserved for patients who are severely compromised or those in whom initial conservative treatment has failed. We describe a case of right atrial myxoma complicated by acute bilateral pulmonary emboli, necessitating emergency pulmonary embolectomy after failed repeated thrombolysis with tissue plasminogen activator.
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CASE REPORT
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A 34-year-old man presented to another hospital following a first episode of syncope. He was in circulatory shock with blood pressure of 87/50 mm Hg and a pulse rate of 140 beats·min–1. He was also in respiratory distress, requiring high-flow supplemental oxygen. Finger clubbing was noted. Blood tests showed a D-dimer level of 3.4 mg·L–1 (normal, <0.36 mg·L–1), mild renal impairment (serum creatinine, 120 µmol·L–1), and mild leucocytosis (white cell count, 11.98 x 109/L). He was resuscitated, and a computed tomography pulmonary angiogram was performed. It showed extensive large emboli in the lobar and segmental pulmonary arteries bilaterally, with right ventricular strain. A polypoid filling defect was also noted in the right atrium. Two doses of 10 units of tissue plasminogen activator (Reteplase) were given consecutively, and heparin infusion was commenced, with no improvement in clinical status. The patient was subsequently transferred to our hospital. Upon arrival, a repeat computed tomography pulmonary angiogram showed persistent bilateral pulmonary emboli despite thrombolysis, and a right atrial filling defect (Figures 1
and 2). A transthoracic echocardiogram showed a severely dilated right ventricle with severe systolic dysfunction. The right atrium was also dilated, and a mobile pedunculated irregular mass was attached to the superior aspect of the atrial septum, measuring 3 x 1.5 cm. The tricuspid valve was normal but there was significant tricuspid regurgitation secondary to annular dilatation. Pulmonary arterial systolic pressure was 41–46 mm Hg. There was diastolic flattening of the interventricular septum, consistent with right ventricular volume overload. The echocardiogram was otherwise normal. The patient continued to deteriorate, requiring escalating inotropic and respiratory support, thus an emergency surgical embolectomy was performed. As the cause of the pulmonary emboli was unknown, an inferior vena cava filter was inserted preoperatively. Cardiopulmonary bypass was instituted, with no cardioplegia initially. Exploration of the right atrium revealed a 1.5 x 1-cm polypoid lesion on the fossa ovalis, consistent with myxoma. Cardioplegia was started, and the lesion was excised with primary closure of the interatrial defect. The pulmonary arterial root was incised longitudinally and the pulmonary emboli were removed by suction and intrapleural pulmonary compression. Postoperatively, the coagulopathy remained, requiring high doses of blood products, desmopressin, human prothrombin complex (Prothrombinex), and recombinant factor VIIa, despite intraoperative aprotinin and additional protamine post-cardiopulmonary bypass. Cardiovascular and respiratory functions were also supported with high doses of adrenaline, noradrenaline, dobutamine, milrinone, nitroglycerine, and nitric oxide. Ischemic hepatitis developed on postoperative day (POD) 2 (alanine amino transferase peaked at 2,000 U·L–1) and polyuric renal failure on POD 3 (creatinine peaked at 487 µmol·L–1). Heparin infusion was recommenced on POD 3, with subsequent warfarin treatment. Histopathology of the right atrial lesion revealed myxoma, and the pulmonary emboli were thrombi with myxoma components. A duplex Doppler study on POD 5 showed no evidence of deep vein thrombosis in the lower limbs. The patient continued to make steady progress and was successfully weaned off inotropic and respiratory support by POD 2, and extubated on POD 3. He was discharged from hospital on POD 13 without further complications.
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DISCUSSION
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Acute massive pulmonary embolism can be defined as >50% obstruction of the pulmonary vasculature, leading to progressive cardiogenic shock. The pathophysiology of this phenomenon is attributed to obstruction of the pulmonary vasculature leading to right heart strain and dilatation. Subsequent interventricular septal displacement with pulmonary vasoconstriction further reduces left ventricular preload and cardiac output. If not terminated, this cycle will eventually lead to right ventricular failure and cardiac arrest. Fast and accurate diagnosis of pulmonary embolism can easily be made with the widespread availability of computed tomography. Perioperative echocardiography can provide further vital information regarding cardiac function.
Although efficacious in the initial treatment of pulmonary embolism, the long-term implications of thrombolysis and catheter embolectomy have yet to be studied. Thrombolysis is associated with higher mortality, major bleeding, and recurrent pulmonary embolism.1 Catheter embolectomy causes fragmentation of the embolus and showering of emboli into the distal pulmonary vasculature. Incomplete embolectomy is associated with pulmonary hypertension and decreased long-term survival. With improvements in surgical and cardiopulmonary bypass techniques, surgical pulmonary embolectomy has increasingly been used as a first-line treatment in pulmonary embolism, with promising results. Despite being performed in a high-risk patient population, mortality after surgical embolectomy remains at approximately 30%.2 In a recent study by Dauphine and colleagues2, surgical mortality was 27%; however, when preoperative cardiac arrest was avoided, this was reduced to 0%. A similar encouraging result was obtained by Leacche and colleagues3 who had a surgical mortality rate of 6%.
When initial thrombolysis has failed, rescue surgical embolectomy has been used successfully, as in this case. Meneveau and colleagues4 showed that patients who underwent rescue surgical embolectomy after failed thrombolysis had a lower hospital mortality than those who underwent repeat thrombolysis (7% vs. 38%). These promising results can also be partly attributed to perioperative insertion of vena caval filters.4 Surgical pulmonary embolectomy should be considered as a first-line treatment for all patients with acute massive pulmonary embolism, and not reserved for those with severe hemodynamic compromise or failed conservative management. When initial thrombolysis fails, surgical embolectomy should be preferred, rather than repeat thrombolysis.
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REFERENCES
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- Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with surgical treatment of massive pulmonary embolism. Lancet 1994;343:576–7.[Medline]
- Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Thorac Surg 2005;79:1240–4.[Abstract/Free Full Text]
- Leacche M, Unic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, et al. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg 2005;129:1018–23.[Abstract/Free Full Text]
- Meneveau N, Séronde MF, Blonde MC, Legalery P, Didier-Petit K, Briand F, et al. Management of unsuccessful thrombolysis in acute massive pulmonary embolism. Chest 2006;129: 1043–50.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:297-299
© 2009 by SAGE Publications
DOI: 10.1177/0218492309104769
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ABSTRACT
INTRODUCTION
