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Interact CardioVasc Thorac Surg 2008;7:412-413. doi:10.1510/icvts.2007.169235 © 2008 European Association of Cardio-Thoracic Surgery
Acute massive pulmonary embolism treated by thrombo-embolectomy using intermittent deep hypothermic circulatory arrestDepartment of Cardiothoracic Surgery, Sint Antonius Hospital, Koekoekslaan, Nieuwegein, The Netherlands Received 5 October 2007; received in revised form 22 January 2008; accepted 22 January 2008
*Corresponding author. Tel.: +31 30 6092104; fax: +31 30 6092120.
Acute massive pulmonary embolism is a life threatening medical emergency resulting in a high mortality rate. Usually, urgent thrombo-embolectomy is performed using double venous cannulation without circulatory arrest. We describe a patient suffering from acute massive pulmonary embolism that was treated by emergency thrombo-embolectomy. Due to back-bleeding the view into the lobar and segmental pulmonary arteries was severely compromised. In order to achieve complete thrombo-embolectomy, intermittent deep hypothermic circulatory arrest was performed.
Key Words: Acute massive pulmonary embolism; Thrombo-embolectomy; Deep hypothermic circulatory arrest
Acute massive pulmonary embolism is a life threatening medical emergency resulting in a high mortality rate of 15% [1]. Usually, urgent thrombo-embolectomy is performed using double venous cannulation without circulatory arrest [2]. In this report we describe the usage of intermittent deep hypothermic circulatory arrest for the treatment of pulmonary embolism.
A 35-year-old woman was referred to our hospital with a history of deep venous thrombosis. She received no anticoagulation or platelet inhibition therapy. On admission the patient complained about coughing, dyspnea and angina pectoris (both, NYHA-IV). Except for her poor clinical condition, physical examination was normal. Blood analysis showed an elevated D-dimer (1.4 ng/ml) and elevated liver enzymes (ASAT 459, ALAT 594, GGT 120, LD 1145). Negative T waves were present on electrocardiography. Echocardiography revealed a dilated right atrium and ventricle and concomitant tricuspid (3/4) insufficiency. Under suspicion of pulmonary embolism, contrast enhanced CT-scan was performed showing massive thrombosis in the right atrium and the common pulmonary artery, the left and right pulmonary artery (Fig. 1a). Subsequently, an urgent thrombo-embolectomy was planned.
During induction of anaesthesiology, the patient went into haemodynamic collapse and total cardiopulmonary bypass was instituted urgently using double venous cannulation. A longitudinal incision was made in the common pulmonary artery and an organised massive clot was completely removed that occluded the origin of the left pulmonary artery. Two separate clots of 6 cm were dissected from the right pulmonary artery. During induction of deep hypothermic (rectal 16 °C) circulatory arrest for 10, 8 and 18 min, the segmental and subsegmental arteries were inspected on both sides after an incision to the right pulmonary artery without opening the pleural space. Several clots were individually removed on both sides. Finally, the right atrium was opened and inspection of the atrial septum and ventricle did not reveal any defects or clots. Rewarming time was used for reperfusion of an extremely compomised and dilated heart due to the acute embolus.
Postoperatively, the patient was anticoagulated according to a standard protocol and received coumadin therapy and intravenous heparin for three days until an INR
Patients suffering from acute massive pulmonary embolism are in a detrimental clinical situation. The only chance for survival can be achieved by emergency thrombo-embolectomy. At induction, most patients get into circulatorycollapse due to the impaired filling of the left ventricle necessitating immediate cardio-pulmonary bypass. Generally, thrombo-embolectomy is performed by using extra-corporeal circulation using Fogarty balloon catheters, suction and opening the pleural space to allow for massaging of the lung as a means to dislodge the peripheral emboli [3]. This approach is characterised by a compromised view into the left and right lobar and segmental pulmonary arteries due to retrograde bleeding from the bronchial circulation often resulting in incomplete thrombo-embolectomy. Usually, massive thrombus formation occurs in the segmental arteries after an acute thrombogenic central occlusion. Based on our excellent experience with thrombo-endarteriectomy using intermittent deep hypothermic circulatory arrest in patients suffering from chronic pulmonary embolism, we performed the same technique in acute massive pulmonary embolism [4]. An optimal view deep into the segmental pulmonary arteries is achieved allowing extensive thrombo-embolectomy on both sides during a limited period of circulatory arrest. In conclusion, we propose intermittent deep hypothermic circulatory arrest as a new and more effective approach for the treatment of acute massive pulmonary embolism in cases in which complete embolectomy was felt to be incomplete.
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Abstract
1. Introduction
2.5. The postoperative course was complicated by pneumonia, treated by antibiotics, and the patient was discharged after 26 days. A control contrast enhanced CT-scan after one year showed a completely open pulmonary circulation on both sides to the peripheral parts of the lungs (Fig. 
