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Video Assisted Surgical Pulmonary Embolectomy
Amit Pawale, Modesto J. Colon, Elizabeth Oswald, Ramachandra Reddy.
Mount Sinai Medical Center, New York, NY, USA.

Video Assisted Surgical Pulmonary Embolectomy
Introduction:
Emergent pulmonary embolectomy is a lifesaving procedure. Removal of clot from the peripheral branches of the pulmonary artery can be difficult. We recently have used a video scope to visualize and extract peripheral pulmonary thrombi.
Materials and Methods:
From October 2014 to December 2014, three patients who were diagnosed with massive acute pulmonary embolism were referred for surgery. There were two females. Two patients had documented deep venous thrombosis, two patients were mechanically ventilated and one patient received CPR preoperatively. All patients had an Inferior vena cava filter placed perioperatively. The mean troponin was 0.58 +/-0.5 ng/ml and mean brain natriuretic peptide was 536 +/-422 .pg/ml. All of them had moderate to severe RV dysfunction on transthoracic echocardiogram (TTE).
A standard pulmonary embolectomy technique was used with cardiopulmonary bypass. After pulmonary ateriotomy and removal of the saddle thrombus a 10mm video-scope was directed sequentially into the left and right pulmonary artery. All emboli from the segmental arteries were
identified and removed. With video assistance careful visualization of the right atrial cavity, the right ventricular apex and the right ventricular outflow tract was performed to rule out the presence of any clot in transit.
Results:
All the three patients had successful recovery. The mean cardiopulmonary bypass time was 126 min +/-36 . The average days on mechanical ventilation were 2 (range 1-3); Inotropic support with low dose milrinone was maintained electively for 5 days The average intensive care stay was 4 days (range 2-5). There were no major complications and the average total length of stay was nine days (range 7-11 days). Two patients had moderate RV dysfunction and one had no RV dysfunction on predischarge TTE.
Conclusion:
Using a video-scope for embolectomy offers several advantages. The procedure is completed through a small arteriotomy in the main pulmonary artery. Direct visualization of the clot minimizes the risk of endothelial injury while maximizing clearance of emboli. The ventricular apex and outflow tract can also be thoroughly visualized. We therefore believe that the use of a videoscope enhances the safety and efficacy of pulmonary embolectomy.


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