Top Things to Know: Surgical Management and Mechanical Circulatory Support in High-Risk PE's: Historical Context, Current Status, and Future Directions
Published: January 23, 2023
Prepared by Johanna A. Sharp, MSN, RN, Science and Medicine Advisor
- Acute pulmonary embolism (PE) are common, affecting patients of all ages and with diverse comorbidities. In 2016, there were an estimated 370,000 cases of PE in the United States (U.S.), with PE hospital admissions tripling over the prior 2 decades.
- According to Medicare data, PE represents a leading cause of cardiovascular death in the U.S. with an associated 30-day and 6-month all-cause mortality of 9.1% and 19.6% in 2010, respectively. Most PE-related mortality is associated with acute right ventricular (RV) failure.
- In acute PE, RV dysfunction due to a sudden increase in RV afterload is the main pathophysiologic insult resulting in mortality. Treatment of PE-associated RV dysfunction requires RV offloading by resolving the mechanical disruption and/or diverting the RV preload causing the distension.
- The development of the cardiopulmonary bypass machine (CPB) was one of the most important advancements in cardiac surgery and surgical treatment of PE. First used in 1961, a CPB machine permits RV recovery by decompressing the dilated and dysfunctional RV through diversion of the cardiac output to a pump and oxygenator allowing the RV to beat in a fully decompressed state with minimal preload and afterload.
- Another advancement is venoarterial extracorporeal membrane oxygenation (VA-ECMO) which decompresses the RV by diverting RV venous return to a pump and oxygenator. The VA-ECMO is more mobile than a CPB machine and may be initiated by a variety of health care specialists in a variety of settings.
- This Scientific Statement focuses on the surgical management of acute PE in high-risk patients, clarifying the most modern evidence for various surgical techniques, the potential shortcomings of historical literature and its impact on current practice, and important gaps in knowledge in this field.
- Over the last two decades, there has been a growing body of literature describing the use of surgical treatments including surgical embolectomy (SE) and/or mechanical circulatory support (MCS) in acute PE, particularly in high-risk patients.
- The authors discuss modern techniques, and outcomes of SE and VA-ECMO and suggest strategies to better understand the role of surgery in the management of PE.
- Modern SE and VA-ECMO demonstrate favorable safety and efficacy profiles for acute PE, particularly in high-risk patient populations. Among patients who do not require preoperative cardiopulmonary resuscitation (CPR), mortality rates of SE are less than 3% and for those who require CPR, survival is approximately 75%.
- The authors suggest areas for action from the PE treatment community to improve the understanding of surgical strategies, and patient outcomes. This includes a need for a refined definition of high-risk PE, more clinical trials, registries, and metrics on treatment efficacy, and an increased effort on education and awareness.
Citation
Goldberg JB, Giri J, Kobayashi T, Ruel M, Mittnacht AJC, Rivera-Lebron B, DeAnda A Jr, Moriarty JM, MacGillivray TE; on behalf of the American Heart Association Council on Cardiovascular Surgery and Anesthesia; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Lifestyle and Cardiometabolic Health; and Council on Peripheral Vascular Disease. Surgical management and mechanical circulatory support in high-risk pulmonary embolisms: historical context, current status, and future directions: a scientific statement from the American Heart Association [published online ahead of print January 23, 2023]. Circulation. doi: 10.1161/CIR.0000000000001117