Fulminant Pulmonary Embolism: Symptoms, Diagnostics, Operative Technique, and Results Christof Schmid, MD, Stefan Zietlow, Thomas 0. F. Wagner, MD, Joachim Laas, MD, and Hans G. Borst, MD Division of Thoracic and Cardiovascular Surgery, Surgical Center, and Division of Pneumology, Medical Center, Hannover, Germany

Fulminant pulmonary embolism associated with cardiac arrest has an extremely high mortality. The feasibility of pulmonary embolectomy initiated during resuscitation is still under discussion. Between January 1975 and January 1991, pulmonary embolectomy was performed in 27 patients, 21 to 79 years old. The diagnosis was established primarily by clinical findings in 18 patients, by angiography and ventilation-perfusion mismatch in 4 patients, and by transesophageal echocardiography in 1 patient seen recently. Eleven patients did not require resuscitation (group 1); 5 patients had to be resuscitated and underwent operation after circulation was reestablished without need of further cardiac massage (group 2); and 11 patients were connected to extracorporeal circulation devices during cardiopulmonary resuscitation (30 to 210 minutes) (group 3). Embolectomy was performed using extracorporeal circulation with the heart beating (n = 2) or fibrillating (n = 15) or using cardioplegia (n = 10). Fifteen patients received a caval clip or ligature at the end

of the procedure. Twelve patients died early postoperatively; the mortality rates were 36%, 60%, and 45% for groups 1, 2, and 3, respectively. Eight patients died of right heart failure, and 2 patients each died of brain death and sepsis. Of the surviving patients, only 1 showed ischemic brain damage. Mean stay in the intensive care unit was 5.1, 7.0, and 9.75 days for groups 1, 2, and 3, respectively. There were no recurrent embolisms during the 15-year follow-up (mean follow-up, 4.6 years). This experience demonstrates that even with subtotal obstruction of the pulmonary arteries, effective cardiopulmonary resuscitation with maintenance of uncompromised brain function is possible. The decision to operate may be based on clinical features without invasive diagnostic procedures. In patients with fulminant pulmonary embolism requiring external cardiac massage, we favor immediate operation, which has an acceptable outcome. (Ann Thoruc Surg 1991;52:1102-7)

F

A complete follow-up of all surviving patients was obtained by telephone or letter.

ulminant pulmonary embolism resulting in hypoxia and right ventricular failure has an extremely high mortality. Many patients die without being referred to a cardiac surgical unit [l]. Survival not only reflects the efficacy of surgical treatment but also depends on the preembolic morbidity, the quality of perioperative cardiopulmonary management, and the postoperative complications. In this study we retrospectively analyze how the degree of cardiopulmonary deterioration determines diagnostic modalities and comment on the feasibility of pulmonary embolectomy initiated during ongoing cardiopulmonary resuscitation.

Material and Methods Between January 1975 and January 1991, 27 patients underwent pulmonary embolectomy using cardiopulmonary bypass in our institution. There were 17 male and 10 female patients, 21 to 79 years old (mean age, 50 years). The medical reports, diagnostic modalities, the intraoperative course, and the postoperative course were reviewed. Presented at the Twenty-seventh Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Feb lb20, 1991. Address reprint requests to Dr Schmid, Division of Thoracic and Cardiovascular Surgery, Surgical Center, Medical School, Konstanty-GutschowStr. 8, 3000 Hannover 61, Germany.

0 1991 by The Society of Thoracic Surgeons

Clinical Features On admission to our unit, 10 patients were breathing spontaneously, and 17 required tracheal intubation and mechanical ventilation. The patients were divided into three groups based on the degree of cardiac deterioration. In 11 patients (group l), adequate to borderline cardiac function could be maintained by moderate to high doses of catecholamines; no external cardiac massage was necessary. This group included all 10 patients who were breathing spontaneously as well as 1 patient requiring artificial respiration. In 16 patients, cardiac failure necessitating external cardiac massage developed, and they had to be intubated and mechanically ventilated. Five of these patients required only temporary or intermittent external cardiac massage (group 2). They underwent embolectomy after at least borderline cardiac pump function had been reestablished. All resuscitative measures failed in 11 patients (group 3). They were taken to the operating room and connected to extracorporeal circulation during continuous external and internal cardiac massage. 'The period of cardiopulmonary resuscitation lasted from 30 to 210 minutes. 0003-4975/91/$3.50

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Table 1. Direct and Indirect Diagnostic Indications of Pulmonary Embolism Indication Indirect ECG, chest roentgenogram, arterial blood gases Shock and resuscitationISwan-Ganz

catheterization History of previous operation/confinement

No. of Patients 27

16 13

to bed

Symptoms of acute phlebothrombosis Transthoracic echocardiography Previous pulmonary embolism/thrombolytic therapy Direct

Pulmonary angiography Ventilatiodperfusion scan Transesophageal echocardiography ECG

=

4 4 1

electrocardiogram.

Diagnostics All patients had symptoms of severe pulmonary embolism including chest pain, cyanosis, tachycardia, decreased blood pressure, or shock. They had dyspnea or were already on artificial respiration. A history of previous operation or prolonged confinement to bed in 13 patients and acute phlebothrombosis in 6 patients suggested the diagnosis. Additional indirect evidence of acute pulmonary embolism was obtained by electrocardiography, chest roentgenography, and Swan-Ganz catheterization. In 18 (67%)of the 27 patients, the diagnosis of fulminant pulmonary embolism and the ultimate decision for urgent surgical intervention were based only on these indirect findings without further confirmation of the embolism by imaging techniques. Table 1 shows the predominant factors influencing the decision to operate on these patients. In only 8 (30%) of the 27 patients was the diagnosis verified by pulmonary angiography or ventilationperfusion mismatch, and in only 1 recent patient did we use transesophageal echocardiography to confirm the diagnosis of fulminant pulmonary embolism (Table 2). The percentage of patients who had ventilationiperfusion scan, angiography, or transesophageal echocardiography in the groups with cardiac massage (group 2, 40%; group 3, 27%) was comparable with that in the group without cardiac deterioration (group 1, 36%). In groups 2 and 3, these studies were done at a time of adequate cardiac function before acute deterioration necessitating cardiopulmonary resuscitation and emergency operation. In group 1, the clinical findings were mild to moderate, and operation was performed because of progressive deterioration of cardiopulmonary function based on the results of the original imaging, which was not repeated.

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Sixteen of the 27 patients were referred to our institution from other hospitals. Five of these patients were in deep shock and were taken to the operating room without any further diagnostic procedure. Two were in group 2 and 3, group 3.

Operative Technique In all patients, pulmonary embolectomy was performed using extracorporeal circulation. Access was always through a median sternotomy. In patients requiring continuous cardiopulmonary resuscitation, external chest compression was followed by manual cardiac massage after rapid sternotomy and pericardiotomy. Aortic and right atrial cannulas were inserted through stab incisions and were initially secured by hand. In 10 patients, the myocardium was protected by cardioplegia (St. Thomas' Hospital solution); in 15, pulmonary embolectomy was performed with the heart spontaneously fibrillating; and in 2, the heart remained beating throughout the procedure. The pulmonary trunk was incised longitudinally, and the thrombus was removed using suction and forceps. In all patients, both pleural cavities were opened, and the peripheral pulmonary vascular bed of each lung was cleared by gentle manual compression. If necessary, the incision was extended into the left pulmonary artery, or the right pulmonary artery was opened through a second incision between the superior vena cava and the ascending aorta for visualization of lobar branches. At the end of the procedure, a caval clip or ligature (2 patients seen early in the series) was placed in 15 patients. The inferior vena cava was approached by extending the median sternotomy caudally to the umbilicus and was exposed by the Kocher maneuver.

Results The early mortality rate for patients undergoing pulmonary embolectomy without a previous cardiovascular collapse (group 1)was 36% (4/11).In patients with temporary external cardiac massage and subsequent operation (group 2), the mortality rate was substantially higher (60%, 3/5), whereas patients with continuous cardiac massage (group 3) had a mortality rate of 45% (5/11), which was nearly identical with the overall mortality rate of 44%. Table 3 summarizes the causes of death in the three patient groups. Of the 12 patients who died, 8 died

Table 2 . Diagnosis and Patient Groups" Indirect Ventilation/ Evidence Pulmonary Perfusion Transesophageal Group Exclusively Angiography Scan Echocardiography

a

Numbers in parentheses are percentages

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of right heart failure, 3 of whom could not be weaned from extracorporeal circulation (embolectomy during cardioplegic arrest, n = 5; embolectomy during ventricular fibrillation, n = 3). Two patients died as a result of brain death and 2, of sepsis. Postoperative complications among the surviving patients occurred predominantly in group 2. In this group, both survivors sustained reversible cardiac and renal failure, whereas in groups 1 and 3, only cardiac failure occurred (43% and 17%, respectively). Ischemic brain damage was found only in 1 patient in group 3 (17%),and septic complications were not significantly increased in either group. The mean stay in the intensive care unit for groups 1, 2, and 3 was 5.1, 7.0, and 9.75 days, respectively. During the follow-up of 15 years (mean follow-up, 4.6 years), the surviving 15 patients were completely rehabilitated and did not sustain another pulmonary embolism regardless of caval clip implantation. All patients except 1 have been on a regimen of Coumadin (crystalline warfarin sodium) (n = 11)or aspirin (n = 2) since embolectomy. In 10 of these patients, a caval clip or ligature was used, and 6 of them have experienced recurrent symptoms of venous thrombosis (Table 4).

Comment Fulminant pulmonary embolism is an infrequent but often fatal disorder despite improved understanding of its pathogenesis, diagnosis, and treatment. The need of surgical embolectomy rarely arises because most fatal emboli cause rapid circulatory collapse and death [2]. The first pulmonary embolectomy was performed by Trendelenburg [3] in 1908, but long-term survival was not achieved until 1924 [4]. It was soon recognized that far more patients died as a result of the procedure than survived. The introduction of extracorporeal circulation for pulmonary embolectomy by Cooley and colleagues [5] and Sharp [6] in 1961 constituted a major advance, and this technique is still the preferred approach. However, concomitant irreversible cardiac arrest still causes an excessively high mortality. The diagnosis is usually suggested by a history of sudden circulatory collapse with progressive hypoxia and an increasing need of catecholamines. It is supported by chest roentgenography, electrocardiography, and SwanGanz catheterization. Direct evidence of pulmonary em-

Table 3 . Causes of Death" Group 1 2 3

a

Cardiac Failure 314 113 415

Numbers in parentheses are percentages

Brain

Sepsis

Death

114

0 113 115

113 0

Table 4. Long-Term Follow-up of 15 Survivors' Variable Coumadin or aspirin (n = 2) No anticoagulant treatment Recurrent venous symptoms Pulmonary embolism relapse a

Caval Clip (n = 10)

No Caval Clip (n = 5)

9 (90) 1 (10) 5 (50) 0

5 (100) 0 2 (40) 0

Numbers in parentheses are percentages.

bolism is provided by ventilation/perfusion scan or pulmonary angiography, the latter being the most accurate method and the method strongly recommended by several authors [7-91. However, transesophageal echocardiography, the speediest diagnostic approach, may ultimately replace pulmonary angiography. In most of our patients (67%), the diagnosis was established by indirect means. There were no false-negative diagnoses among these patients. We therefore agree with Clarke and colleagues [101 that angiography and pulmonary ventilation/perfusion scan are not mandatory diagnostic procedures. They may cause an unacceptable delay, as death can occur at any moment. We believe that these methods should be reserved for patients whose cardiac function is still stable. In patients who require cardiac massage, diagnostic procedures should be reduced to a minimum, and the patient taken to the operating room as soon as possible. However, in certain situations, the clinical differentiation between acute myocardial infarction and fulminant pulmonary embolism may be difficult, especially when medical history, electrocardiogram, respiratory compromise, and chest roentgenogram do not reveal typical findings. If an urgent surgical intervention seems indicated, clinical decision making is then based mainly on the results of Swan-Ganz catheterization. There are only a few reports [ll]suggesting that patients with pulmonary embolism who require mechanical ventilation or cardiac massage may be candidates for thrombolytic therapy. As no randomized trial exists, larger patient series will be necessary to compare the results of embolectomy and thrombolysis under these circumstances. We agree with Gray and co-workers [ 121 that decisions regarding surgical intervention have to be based on the needs of the individual patient. In patients with acute mild to moderate pulmonary embolism, thrombolysis is the therapy of choice unless contraindicated for other reasons. However, in patients requiring an increasing dose of catecholamines and with progressive hypoxia necessitating intubation and mechanical ventilation, thrombolytic therapy currently appears inappropriate. We believe these patients should undergo urgent surgical embolectomy. In our experience, the mortality rate for these patients was 36%. Our group 2 patients, who had operation after reestablishment of borderline cardiac function, fared less well than group 3 patients, those requiring embolectomy during continuous resusci-

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tation, both in terms of cardiac and renal complications. This finding indicates that prolonged nonsurgical management of such patients seems to be inferior to immediate surgical intervention. In the case of acute cardiac deterioration because of subtotal obstruction of the pulmonary arteries mandating resuscitation, continuous external cardiac massage and artificial respiration have been sufficient to avoid lethal hypoxic brain damage. The most widespread technique for pulmonary embolectomy is that described by Cooley and associates [5] and Sharp [6]. In a multicenter study, Del Campo [13] reviewed the cases of 651 patients operated on by this technique. The overall early mortality rate was 40% compared with 51% for patients having operation without cardiopulmonary bypass. Gray and co-workers [14] reported a hospital mortality of 11%in patients who had not sustained a cardiac arrest before embolectomy and 64% in those who had. There is a difference of opinion about whether patients requiring permanent external cardiac massage should be referred for surgical intervention. We advocate rapid median sternotomy with placement of arterial and venous cannulas during intermittent external and internal cardiac massage. Other groups [9, 121 prefer femoral vein-femoral artery partial cardiopulmonary bypass. We believe this approach should be reserved for patients who cannot immediately undergo operation and therefore benefit from preoperative cardiovascular stabilization. In our experience, femoral cannulation and bedside institution of extracorporeal circulation may gain no time and may even delay embolectomy. In conclusion, our experience demonstrates that effective resuscitation with maintenance of uncompromised brain function is possible in patients with fulminant pulmonary embolism and resulting cardiopulmonary failure. In case of acute cardiac deterioration leading to external cardiac massage, no time-consuming efforts should be made to reestablish sufficient cardiac pump function. The diagnosis should and, in fact, can be established by clinical features only, thereby allowing pulmonary embolectomy to be initiated immediately, even if

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continuous external cardiac massage is necessary before the patient is connected to extracorporeal circulation.

References 1. Coon WW, Coller FA. Some epidemiologic considerations of thromboembolism. Surg Gynecol Obstet 1959;109:487-501. 2. Donaldson GA, Williams C, Scannell JG, Shaw RS. A reappraisal of the application of the Trendelenburg operation to massive fatal embolism. N Engl J Med 1963;268:1714. 3. Trendelenburg F. Ueber die operative Behandlung der Emboli der Lungenarterie. Verh Dtsch Ges Chir 1908;3789-103. 4. Kirschner M. Ein durch die Trendelenburgsche Operation geheilter Fall von Emboli der Art. pulmonalis. Arch Klin Chir 1924;133:312-59. 5. Cooley DA, Beall AC Jr, Alexander JK. Acute massive pulmonary embolism: successful surgical treatment using temporary cardiopulmonary bypass. JAMA 1961;177:283-6. 6. Sharp EH. Pulmonary embolectomy: successful removal of a massive pulmonary embolus with the support of cardiopulmonary bypass: case report. Ann Surg 1926;156:14. 7. Sautter RD, Myers WO, Ray JF, Wenzel FJ. Pulmonary embolectomy: review and current status. Prog Cardiovasc Dis 1975;5:371-89. 8. Tschirkov A, Krause E, Elert 0, Satter P. Surgical management of massive pulmonary embolism. J Thorac Cardiovasc Surg 1977;75:7363. 9. Mattox KL, Feldtman RW, Beall AC, DeBakey ME. Pulmonary embolectomy for acute massive pulmonary embolism. Ann Surg 1982;6:726-31. 10. Clarke DB. Pulmonary embolism re-evaluated. Ann R Coll Surg Engl 1981;63:1&24. 11. Scholz KH, Hilmer T, Schuster S, Wojcik J, Kreuzer H, Tebbe U. Thrombolyse bei reanimierten Patienten mit Lungenembolie. Dtsch Med Wochenschr 1990;115:9365. 12. Gray HH, Miller GAH, Paneth M. Pulmonary embolectomy: its place in the management of pulmonary embolism. Lancet 1988;25:1441-5. 13. Del Campo C. Pulmonary embolectomy: a review. Can J Surg 1985;28:111-3. 14. Gray HH, Morgan JM, Paneth M, Miller GAH. Pulmonary embolectomy: indication and results. Br Heart J 1987;57:572. 15. Robison RJ, Fehrenbacher J, Brown JW, Madura JA, King H. Emergent pulmonary embolectomy: the treatment for massive pulmonary embolus. Ann Thorac Surg 1986;42:52-5.

DISCUSSION DR LAZAR J. GREENFIELD (Ann Arbor, MI): I congratulate Dr Schmid on his presentation and thank him for the opportunity to review the manuscript. An aggressive approach to massive pulmonary embolism is certainly appropriate, but there continue to be controversies regarding the indications and patient stratification, methods of diagnosis, and type of operative approach. The overall operative mortality rate of 44% achieved in this study is comparable with the mortality rates in other reported experiences, but some would disagree with the need for the procedure in patients whose condition had stabilized after the embolism without ventilatory support. In fact, it is surprising that the mortality rate was 36% in this group, which Dr Schmid and associates should explain. What is remarkable, however, is the fact that the diagnosis was made on clinical grounds alone in two thirds of these patients.

Because the clinical diagnosis of massive pulmonary embolism in every large series in the United States has been wrong in 70% to 80% of patients as confirmed by angiography, it would be very helpful for Dr Schmid and associates to share their clinical expertise. Is it true that you found emboli in every patient who underwent exploration over the 16 years of the study? Which clinical features or pulmonary arterial hemodynamic findings did you find to be specific? These details are not in the manuscript. Having performed embolectomy, you chose to clip the vena cava in only 15 patients. How were they selected? There were late venous symptoms in 60% of these patients. In how many were the venae cavae obstructed? As you know, this is the complication to be expected when a clip is used instead of a filter. It seems clear that an overall mortality rate of 44% still leaves something to be desired. Therefore I will mention the alternative

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technique of catheter pulmonary embolectomy. The procedure is usually performed in the radiology suite once the diagnosis has been confirmed by angiography. After exposure of the jugular vein under local anesthesia, a steerable cup-catheter is inserted and positioned under fluoroscopy adjacent to the embolus. Syringe suction captures the embolus in the cup and holds it there while the catheter and embolus are withdrawn. We have had experience with this technique in 32 patients. The overall mortality rate was 22%. This favorable experience is not unique to us, but has been demonstrated by others in the United States and also in a series from France. In that series, the overall mortality rate was 28%. However, the mortality rate was only 18% in those patients in whom emboli could be removed by the catheter technique. Therefore, there is an alternative approach for the patient with massive embolism who still can sustain a blood pressure with inotropic support. There obviously remains a role for open embolectomy in the patient in whom the catheter procedure fails or in the patient who requires constant closedchest massage

DR ERNEST0 J. MOLINA (Minneapolis, MN): If heparin sodium therapy is the only alternative offered to the patient with pulmonary embolism, the most critically ill patients would have no choice but to undergo pulmonary embolectomy, with substantial morbidity and mortality. My colleagues and I at the University of Minnesota have developed a different approach for all patients with massive pulmonary embolism. During the past 7 years, we have treated 14 patients by direct infusion of urokinase at the time the diagnostic arteriogram is obtained. Our standard protocol calls for a bolus injection of urokinase directly into the clot in the pulmonary artery at a dose of 2,200 Ulkg. This is followed by continuous infusion of the same dose per hour through the same catheter, which is left in position until the clot is cleared. The most important safety factor to monitor is the fibrinogen level during urokinase therapy. Keeping the level at 2 g/L, we have not experienced bleeding in any of our patients. Two of the patients needed resuscitation and were in shock. The other 12 had sizable emboli but did not require resuscitation. Clearing of clots was relatively rapid, ranging from 90 minutes to 24 hours. There were no deaths, and the patients were discharged from the intensive care unit in 48 hours. We believe that implementing this protocol in patients with or without recent operation offers a better alternative than embolectomy on cardiopulmonary bypass. Realistically, it takes a minimum of 1 hour for a patient suspected of having a pulmonary embolism to be actually on cardiopulmonary bypass in the operating room. Our approach is prompt, effective, and safe. AS a corollary, we have not operated on any patient for massive pulmonary embolism during the last 7 years. DR AGUSTIN ARBULU (Detroit, MI): I congratulate Dr Schmid and his associates for resurrecting a valuable operation. Our experience is almost identical to theirs. It comprises 15 years and 20 patients, 7 of whom died. I have a question that is illustrated by the case of a 65-year-old, 112.5-kg diabetic patient who had a fulminant pulmonary embolism in October 1976. The removed embolus grew Eschevichia coli, which originated in a right hydronephrotic ureter, which resulted in a right ileo-femoral vein thrombosis. The patient survived pulmonary embolectomy and lived an additional 12 years, dying of cancer of the pancreas. Dr Schmid, did you observe any septic pulmonary emboli in your series?

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DR ARTHUR C. BEALL, JR (Houston, TX): I have two brief points to make. First, it is of interest that this presentation comes from Germany and that the February issue of The 14nnals of Thoracic Surgery has a large series from Paris. Current interest in pulmonary embolectomy using cardiopulmonary bypass seems to be centered in Europe, whereas it has become less and less used in the United States in the 30 years since it was first reported here. One of the reasons pulmonary embolectomy got a bad name in this country is that several large series were reported in which more than 50% of the patients did not have a pulmonary embolus. You would not expect very good results from pulmonary embolectomy in a patient who does not have a pulmonary embolus. Second, I would like to raise the same warning that Dr Greenfield did, namely, that operating on clinical grounds alone will produce a number of patients without a pulmonary embolus. With the use of temporary cardiopulmonary bypass from femoral vein to femoral artery and with the portable equipment that is currently available, one can resuscitate the patient, take him or her to the radiology suite for a pulmonary angiogram, and then do pulmonary embolectomy only on those who actually have a pulmonary embolism. DR KARL J. KARLSON (Boston, MA): I commend Dr Schmid and the group from Hannover on their series of pulmonary embolectomies. 1 will comment on our own experience in Boston with this operation, an experience primarily reflecting the work of Dr Robert Berger. Based on information in the literature and our own autopsy studies, we have established fairly firm criteria for acute pulmonary embolectomy. We have found that the mortality rate for an obstruction of more than 50% of the pulmonary vasculature approaches 50%, and this figure rises to 70% if the patient requires vasopressor therapy. If clinical deterioration continues, the mortality rate approaches 100%. We have performed acute pulmonary embolectomies on 22 patients over the past two decades. All patients had femoral cannulation for cardiopulmonary bypass before the induction of general anesthesia, but none were placed on bypass until they manifested hemodynamic instability. Seventeen of these patients actually did require the institution of bypass before anesthesia was induced because their condition was unstable. Six of the patients died. Of special note are 2 patients who were categorized as dying of unrelated causes. These patients represent errors in diagnosis. They did not have pulmonary angiography and had operation on on the basis of clinical findings alone. They could not be weaned from bypass and died in the operating rsoom. Dr Schmid and his colleagues operated on most of their patients on the basis of clinical findings, and it is surprising to me that they report no negative pulmonary artery explorations. I, too, would like to ask them how confident they are in their ability to make the diagnosis of acute pulmonary embolism without a pulmonary angiogram. I commend The Society for putting this paper about pu:lmonary embolectomy on the program. It was exactly 60 years ago this month that Dr John Gibbon wrote the following wor’ds on a patient’s chart at the Massachusetts General Hospital while working as a research fellow for Dr Churchill: During that long night’s vigil, watching the patient struggle for life, the thought naturally occurred to me that the patient’s life might be saved if some of the blue blood in her veins could be continuously withdrawn into an extracorporeal blood circuit, exposed to an atmosphere of oxygen, and then returned to the patient by way of a systemic artery in a central direction. Thus, some of the

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patient’s cardiorespiratory functions might be temporarily performed by the extracorporeal blood circuit while the massive embolism was surgically removed. These words have obviously affected us all profoundly.

DR SCHMID: The number of remarks and questions shows that there is a great interest in this field. With respect to Dr Greenfield, we certainly also believe that an overall mortality rate of 44% covering a 16-year experience is not satisfying. The patients who had operation after stabilization (group 1) were, some would say, ideal candidates for thrombolysis. However, most of them were operated on from 1983 to 1988, when thrombolysis was not available. After 1988, thrombolytic therapy was initiated by our pulmonologists and angiologists. It is now performed even during resuscitation, as indicated in a report by a group in Gottingen, Germany, who had a mortality rate of 45% under these circumstances. However, our survival rate of 55% in patients requiring resuscitation without the possibility of angiography (group 3) is, we believe, the best that can be achieved. We

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think these results are possible only if there is no delay because of diagnostic procedures, that is, patients are immediately referred for surgical intervention. Dr Molina described a thrombolytic protocol for direct urokinase infusion into the pulmonary artery at the time of the diagnostic arteriogram. However, most of the patients in group 3 required ongoing external cardiac massage, thus making angiography absolutely impossible. Dr Arbulu asked about septic emboli. Two patients died of a fulminant sepsis, but in neither could bacteria be cultured from the embolus. Last, I will comment on the warnings of Dr Beall, Dr Karlson, and Dr Greenfield about operating on clinical grounds alone. In our experience, fulminant pulmonary embolism requiring resuscitation should be managed aggressively. Pulmonary angiography is important but is not always mandatory. If it is not available or is impossible to perform because of ongoing external cardiac massage, the indication for immediate operation can and should be based on clinical findings only.

Fulminant pulmonary embolism: symptoms, diagnostics, operative technique, and results.

Fulminant pulmonary embolism associated with cardiac arrest has an extremely high mortality. The feasibility of pulmonary embolectomy initiated during...
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