Editor - I read with great interest Sheares' excellent review article on the management of patients with suspected acute pulmonary embolism (PE) (Clin Med April 2011 pp 156–9). I would, however, like to comment on the author's recommendations regarding the treatment of high-risk PE, previously known as massive PE.
Sheares, citing the study of Jerjes-Sanchez et al1 which states that thrombolysis improves survival in patients with high-risk PE. However, the author neglects to report the observations from the International Cooperative Pulmonary Embolism Registry.2 Although admittedly somewhat counterintuitive, the findings of this landmark study were that thrombolysis did not reduce mortality or recurrence of PE at 90 days in high-risk PE.
Sheares confines the role of surgical embolectomy in high risk PE to patients who have failed thrombolysis or in whom thrombolysis is contraindicated. However, there is an emerging body of evidence supporting the use of primary embolectomy. Successful surgical embolectomy, using temporary cardiopulmonary bypass, was first reported by Denton Cooley 50 years ago.3 Thirty years later, Gulba et al compared the outcome of 13 patients with massive PE treated with surgical embolectomy and 24 such patients treated with thrombolysis.4 The surgically treated patients had a lower death rate as well as lower rates of bleeding and recurrence of PE. More recently, Fukuda et al have reported an operative mortality of only 5% in patients with massive PE undergoing emergent pulmonary embolectomy.5
Accordingly, primary surgical embolectomy should be considered favourably in centres with on-site cardiothoracic surgery. Given that the author's institution is an internationally acclaimed cardiothoracic centre, I would welcome her comments on her experience in this area.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2011 Royal College of Physicians
References
How do I manage a patient with suspected acute pulmonary embolism?
Editor - I would like to thank Professor Glazier for highlighting areas in which there is a paucity of randomised controlled trial evidence.
He mentions the observational study from the International Cooperative Pulmonary Embolism (PE) Registry reported by Kucher et al. In the subgroup of patients with acute PE and a systemic arterial pressure less than 90 mmHg (high-risk PE), thrombolysis did not appear to reduce mortality. Of note patients were not randomised and the patients who received thrombolysis had a higher rate of right ventricular hypokinesis raising the possibility that the thrombolysed group had more severe disease. Hence it is difficult to comment on the role of thrombolysis from this observational study.
In the absence of adequately powered randomised controlled trials, Wan et al performed a meta-analysis of randomised trials comparing thrombolytic therapy with heparin in patients with acute PE. In a subgroup analysis, thrombolysis was associated with a significant reduction in death in the trials that included patients with haemodynamically unstable PE.
In terms of my centre's experience of primary surgical embolectomy, Papworth Hospital is a tertiary specialist cardiothoracic centre without an accident and emergency department. Patients are referred with complex thromboembolic disease (for example right ventricular thrombus) or chronic thromboembolic pulmonary hypertension who proceed to pulmonary endarterectomy. As far as I am aware, there are no randomised controlled trials of primary embolectomy versus thrombolysis in patients with high-risk PE. From the surgical series reported in experienced cardiothoracic centres, surgical embolectomy may be a useful treatment in high-risk PE if immediately available.
Footnotes
Please submit letters for the editor's consideration within three weeks of receipt of Clinical Medicine. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk
- © 2011 Royal College of Physicians
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