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Acute pulmonary embolism and surgical treatment

Department for Thoracic, Cardiac, and Vascular Surgery, University Göttingen, Göttingen 37075, Germany

Acute massive pulmonary embolism treated by thrombo-embolectomy using intermittent deep hypothermic circulatory arrest

I read with interest the article by Van Putte et al. [1] in which they describe intermittent application of deep hypothermic circulatory arrest for open pulmonary thrombo-embolectomy in acute massive embolism.

Massive pulmonary embolism is a life threatening condition and urgent treatment is indicated immediately after confirmation of diagnosis. Open pulmonary embolectomy is in most cases performed in patients with hemodynamic instability or contraindications for thrombolytic or interventional treatment and results are regarding the acceptable severity of illness. Surgical techniques performed are still controversial.

I agree with the authors that deep hypothermic circulatory arrest is an excellent technique in cases of chronic pulmonary embolism, but I think that deep hypothermic circulatory arrest will not be needed in cases of acute pulmonary embolism. Although longitudinal incision of pulmonary artery is in many cases performed [2, 3], like in the present one, I would suggest semicircular incision of the main pulmonary artery just before pulmonary bifurcation. Through this incision and using rigid suction segmental pulmonary arteries can be viewed well, especially from the left side. Viewing from the right side is often compromised and can be facilitated in some cases with additional direct incision of right pulmonary artery at the level of right pulmonary artery trifurcation after dissection of tissue between ascending aorta and superior cava vein. I believe that use of Fogarty catheters should be avoided, due to risk of perforation into fragile lung tissue resulting in intrapulmonary bleeding. In addition, compression of lungs very often reveals mobilized peripheral clots and should be performed carefully.

Two other points of view are very important; first, bicaval cannulation should be done making careful inspection of right atrium, interatrial septum, and right ventricle possible and safe, avoiding recurrent embolism of clots remaining in right heart, and second, reperfusion of the extremely dilated and compromised right ventricle is essential. The technique described by Van Putte and colleagues uses rewarming time for extensive reperfusion.

Anyway, I believe that application of deep hypothermic circulatory arrest during pulmonary embolectomy should be a good option in cases of reccurent pulmonary embolism with fresh and old clots in pulmonary artery tree.

	References

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1. Van Putte BP, Bantal N, Snijder R, Morshuis WJ, Van Boven WJ. Acute massive pulmonary embolism treated by thrombo-embolectomy using intermittent deep hypothermic circulatory arrest. Interact CardioVasc Thorac Surg 2008;7:412–414.[Abstract/Free Full Text]
2. Dauphine C, Omari B. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Thorac Surg 2005;79:1240–1244.[Abstract/Free Full Text]
3. Sadeghi A, Brevetti GR, Kim S, Burack JH, Genovese MH, Distant DA, Kodavatiganti R, Lowery RC. Acute massive pulmonary embolism: role of the cardiac surgeon. Tex Heart Inst J 2005;32:430–433.[Medline]

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