More Patients May Benefit from Pulmonary Embolism Surgery

A new scientific statement from the American Heart Association presents evidence that more high-risk patients with pulmonary embolism could benefit from surgical management, and refined definitions of risk level may help identify which patients could benefit.¹

Pulmonary embolism, a blood clot that travels to the lungs, is the third leading cause of cardiovascular death in the United States. Nearly 45% of patients experiencing pulmonary embolism will progress to severe symptoms, in which the clot causes high pressure in the lungs and subsequent damage to the right heart chamber, with a high risk of death. Even with current guideline-directed therapies, there is a high rate of death, with approximately 40% of cases in some patient populations.¹

Treatment options include anticoagulation therapy or thrombolysis, or advanced surgical interventions such as surgical embolectomy and mechanical circulatory support. Surgical techniques are often used as a last resort after other treatments are unsuccessful, but the statement suggests that considering surgery earlier may help improve survival for patients with severe pulmonary embolism.¹

“This statement demonstrates that modern surgical management strategies and mechanical circulatory support results in excellent survival (97%) even among the sickest patients, including those who present with cardiac arrest and have had CPR,” said Joshua B. Goldberg, MD, chair of the statement writing group and an attending cardiothoracic surgeon at the Westchester Heart and Vascular Center in Valhalla, New York, in a press release.¹

The writing group proposes strategies to determine pulmonary embolism risk more accurately and to identify which patients may benefit from surgical intervention earlier. They also suggest increased education for clinicians to encourage the use and integration of surgical strategies earlier in treatment.¹

According to the statement, the surgical and mechanical circulatory report literature reviewed by the authors represents the most robust data on the high-risk pulmonary embolism population because most catheter-directed therapy and systemic thrombolytic research has focused on patients at intermediate risk.²

The authors found that surgical embolectomy and venoarterial extracorporeal membrane oxygenation (VA-ECMO) demonstrate favorable safety and efficacy profiles when accounting for the baseline level of illness in the populations for whom they are used. Among patients who do not require preoperative CPR, mortality rates with surgical embolectomy are less than 3%, and survival is even approximately 75% among those who require CPR.²

Similarly, although VA-ECMO is used in the most severe of the high-risk population, with preoperative CPR needed in the majority of patients, reported short-term survival rates are approximately 70%.²

“On the basis of the outcome data described previously, expansion of the use of [surgical embolectomy] and [mechanical circulatory support] may provide additional survival benefit in a population in whom the current treatment paradigms continue to be associated with exceedingly high mortality,” the authors wrote in the statement.²

The statement also supports the development of patient registries, particularly focused on data that provide useful context for clinicians and surgeons to understand the progression from intermediate to high-risk pulmonary embolism and treatment outcomes across patients at various risk levels.¹

“Modern surgical strategies and mechanical circulatory support are drastically underutilized,” Goldberg said in the press release. “It is the hope of the multidisciplinary group of authors that this scientific statement will provide a greater awareness of the safety and efficacy of modern surgical management and mechanical circulatory support in treating the most unstable patients so that lives may be saved. In addition, we hope this statement will facilitate improved understanding of the disease process and effective treatments and encourage future research to improve the survival of patients with this common and deadly disease.”

REFERENCES

1. New statement suggests more patients may benefit from surgery for pulmonary embolism. News release. American Heart Association; January 23, 2023. Accessed January 23, 2023. https://newsroom.heart.org/news/new-statement-suggests-more-patients-may-benefit-from-surgery-for-pulmonary-embolism?preview=7e29
2. Goldberg JB, Giri J, Kobayashi T, Rual M, et al. 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. Circulation.2023;1 47:00-00. doi:10.1161/CIR.00000000001117.