Pulmonary embolectomy: review of a 15-year experience and role in the age of thrombolytic therapy.

OBJECTIVE Surgical intervention for fulminant pulmonary embolism is nowadays most commonly restricted to patients with failure of or contraindication to thrombolytic therapy. Such a second choice indication may alter operative risks or late outcome, and this was investigated in a retrospective study. MATERIAL AND METHODS Thirty-six patients (17 male, mean age: 50.6 +/- 15.5 years) with fulminant pulmonary embolism of either the pulmonary trunk or one of the pulmonary arteries and at least one contralateral segment underwent pulmonary embolectomy on cardiopulmonary bypass during a 15-year period (1979-89: 31 patients, group I; 1990-94: 5 patients, group II). Group II included only patients who did not meet the criteria for acute thrombolysis. All patients were in strongly compromised circulatory conditions (29/36 high dose catecholamines, 20/36 mechanical ventilation, 14/36 pre-operative cardiopulmonary resuscitation). RESULTS The perioperative mortality rate was 26% in group I (8/31 patients, 7 with pre-operative cardiac arrest) and 20% in group II (1/5 patients not related to failure of previous thrombolytic therapy). Severe but non-fatal complications occurred in six patients who fully recovered following treatment. Follow-up was completed to 93% (25/27 patients) and comprised a total of 248 patient-years (mean: 119 months). Twenty-three out of 25 patients (92%) were in functional class I or II (NYHA). No recurrent pulmonary embolism or late clinical symptoms related to embolectomy were observed. One patient died 8 years postoperatively (late mortality: 0.4% patient-year). There was no difference between group I and group II regarding perioperative mortality, complications and late results. CONCLUSIONS Late results after pulmonary embolectomy are excellent in respect to functional class and late mortality. Early mortality is closely associated with preoperative cardiac arrest. Previous thrombolysis does not alter the perioperative risks, occurrence of complications or late outcome after surgical intervention.