**5. Conclusion**

with preoperative cardiac arrest (59% vs 29%) [47]. Prospectively studied patients that have failed an initial course of thrombolytics have lower mortality with embolectomy than with a second course of thrombolysis (7% vs. 38%) [48]. More recent studies have begun to examine results in patients not meeting strict criteria of sustained hypotension or cardiogenic shock, but rather using evidence of RV dysfunction as an expanded criteria for pulmonary embo‐ lectomy, with operative mortality in contemporary series being 6-8% [49-53]. Expediency of operation has also found to have improved outcomes, particularly with surgical therapy oc‐ curring within 24 hours of diagnosis [54]. The improvement in operative mortality in the modern era may be due to several factors: improved patient selection, early identification of RV dysfunction with contemporary diagnostic modalities, extent of pulmonary thrombecto‐ my to prevent residual thrombus and thus pulmonary hypertension, the prophylactic use of IVC filters, and early operation before the development of cardiogenic shock or the need for cardiopulmonary resuscitation, both of which confer a significantly increased in-hospital mortality (25% and 65%, respectively vs 8.1%) [55]. By instituting a criteria of RV dysfunc‐ tion as an indication for pulmonary embolectomy, the population to be considered expands

**4.3. Thrombolytics, special populations, catheter-based therapy, and IVC filters**

mendations are against thrombolytics in stable patients (Grade 1C) [58].

The benefit of thrombolytic therapy in the treatment of acute PE has been controversial. A meta-analysis showed that overall, there was no significant reduction in PE or death when comparing thrombolysis with heparin; neither was the risk of major bleeding significantly increased. Subgroup analysis showed a significant reduction in PE and death in the trials that included patients with major (i.e. hemodynamically unstable) PE and no benefit in those trials that excluded those patients [56]. A review of current evidence concluded that, "Despite the lack of a verifiable mortality benefit associated with thrombolytic therapy in patients with massive PE resulting in hemodynamic instability, most clinicians accept this clinical scenario as indication for thrombolytics and it is guideline based" [57]. In the most recent guidelines (2012), The American College of Chest Physicians evidence for thrombo‐ lytic administration is graded 2C for unstable patients without high bleeding risk; recom‐

Because the effects are systemic, thrombolytics poses a risk of serious perioperative bleeding and should be approached with caution in patients with acute massive PE that may be con‐

This decision is of particular interest in populations whose underlying disease places them at increased risk of bleeding elsewhere. Trauma patients with immobility and/or traumatic brain injury are prone to DVT and PE; sites of bleeding risk include concomitant solid organ injury and intracranial hemorrhage. Reluctance to place prophylactic IVC filters has been due to filter-related complications and inconsistent follow-up; this has been tempered by more recent studies showing low complication rates and safe retrievability at greater inter‐ vals. Limited data consisting of matched-control trials have shown reduced PE and PE-relat‐ ed mortality rates with prophylactic filters [59]. Yet, prophylactic IVC filter placement in atrisk patients remains a Level III recommendation by the Eastern Association for the Surgery

to include patients with submassive PE.

406 Principles and Practice of Cardiothoracic Surgery

sidered for surgical embolectomy.

Acute massive pulmonary embolism is a disease best treated by multimodality therapy, be‐ ginning with systemic heparinization and IVC filter placement. A multitude of diagnostic modalities, including transesophageal echocardiography and computed chest tomography, are available in the contemporary setting to guide risk-stratification and to assess RV dys‐ function. Contemporary series of pulmonary embolectomy have demonstrated low opera‐ tive mortality with improved surgical techniques, and survival is increased when operative therapy occurs before the development of hemodynamic collapse. Thus, the modified Tren‐ delenburg procedure with extended distal pulmonary embolectomy should be part of an ag‐ gressive approach to an otherwise lethal problem in the current age.
