Minimally Invasive Surgical Pulmonary Embolectomy: A Safe And Effective Alternative To Conventional Sternotomy
Chetan Pasrija, Aakash Shah, Michael Rouse, Mehrdad Ghoreishi, Gregory J. Bittle, Francesca Boulos, Bartley P. Griffith, Zachary N. Kon.
University of Maryland School of Medicine, Baltimore, MD, USA.
Background: Surgical pulmonary embolectomy (SPE) has gained popularity over the past decade as multiple series have reported excellent outcomes in the treatment of submassive and massive pulmonary embolism (PE). However, a significant barrier to the growth of SPE remains the large incision and long recovery after a full sternotomy. We report the safety and efficacy of utilizing a minimally invasive approach to SPE.
Methods: All consecutive patients undergoing minimally invasive SPE (2015-2016) were retrospectively reviewed. The minimally invasive approach included a 5-7cm skin incision with upper hemi-sternotomy to the 3rd intercostal space. Bicaval venous and central aortic cannulation was utilized. Separate incisions were made on the right and left main pulmonary artery (PA) and thrombus was removed up to the subsegmental level of each PA branch. The primary outcome was in-hospital and 30-day survival. Secondary outcomes included improvement in right ventricular (RV) dysfunction, operative time, ventilator time, length of stay (LOS), renal failure, deep sternal wound infection (DSWI), sepsis and postoperative stroke.
Results: 10 patients were identified with a median age of 46 (IQR: 40-53) years. The median preoperative troponin was 0.72 (IQR: 0.32-0.96) ng/mL and NT-proBNP was 880 (IQR: 658-5440) pg/mL. All patients had an RV/LV ratio >1.0. 3 patients underwent concomitant procedures at the time of SPE, including paraesophageal hernia repair, mediastinal mass removal, and decannulation of peripheral venoarterial-extracorporeal membrane oxygenation. 2 patients with acute on chronic pulmonary embolic disease additionally required pulmonary thromboendarterectomy. The median RV dysfunction decreased from severe preoperatively to none at discharge. The median operative time was 216 (IQR: 187-223) minutes with 78 (IQR: 61-95) minutes of cardiopulmonary bypass time. Median ventilator time was 8 (IQR: 3-23) hours with an ICU LOS of 2.7 (IQR: 1.8-3.2) days and hospital LOS of 4 (IQR: 4-6) days. In-hospital and 30-day survival was 100%. No patient suffered postoperative renal failure, DSWI, sepsis, or stroke.
Conclusions: Minimally invasive SPE appears to be a safe and effective approach in the treatment of patients with a submassive or massive PE. A larger, prospective analysis comparing this modality to conventional surgical pulmonary embolectomy may be warranted.
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