BACKGROUND: Five years ago, we began an aggressive multidisciplinary approach to the treatment of massive pulmonary embolus (PE), centering on rapid diagnosis with contrast chest CT to define anatomy as well as clot burden, and transthoracic echo to document RV strain, with immediate surgery when appropriate. We now report our results in 43 consecutive patients in whom this aggressive approach was used.
METHODS: From 10/99 to 9/03, 43 consecutive patients (28M/15F, median age 58 years [range 24-86]) underwent emergency surgical embolectomy for massive PE. The indications for surgery were contraindications to thrombolysis (21/43, 48%), or the combination of RV strain and either failed medical treatment (4/43, 10%), or the presence of massive central clot burden (18/43, 42%). Preoperatively, 12 (28%) patients were in cardiogenic shock and 5 (11%) were in full cardiac arrest.
RESULTS: There were 4 (10%) operative deaths, 2 with preoperative cardiac arrest. Two patients (including one of the two who died) received a right ventricular assist device. Thirty-five (81%) patients had a caval filter placed intra-operatively. Median length of stay was 11 days (range 3-75 days). Median follow-up was 27 months (range 2-50 months). There were 6/40 (14%) late deaths, 5 with subsequent diagnosis of cancer. Actuarial survival at 1 and 3 years follow-up was 86% and 83%, respectively.
CONCLUSIONS: Based on these results, we have changed our practice to offer surgical embolectomy not only in hemodynamically compromised patients but also in patients with anatomically extensive central PE and RV dysfunction.

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