[Surgical aspects of fulminant pulmonary embolism]

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 October 1992, embolectomy was performed in 34 patients, 21 to 79 years of age. Diagnosis was established primarily by indirect parameters (medical history, ECG, blood gas analyses, Swan-Ganz catheter in 22 cases). Only in 12 instances, imaging techniques as angiography, ventilation perfusion mismatch, and transesophageal echocardiography were performed. Fifteen patients did not require resuscitation (group A); 6 had to be resuscitated and underwent surgery after reestablishing circulation with catecholamines (group B); 13 patients were connected to extracorporeal circulation during continuous cardiopulmonary resuscitation (30 to 210 minutes) (group C). Embolectomy was performed using extracorporeal circulation with the heart beating (n = 8), or fibrillating (n = 15), or using cardioplegia (n = 11). Twenty-two patients received a caval clip or ligature at the end of the procedure. Fifteen patients (44%) died early postoperatively. The mortality rates for groups A, B, and C were 33%, 66% and 46%, respectively. Nine patients died of right heart failure, 4 of brain death, and 2 of septical complications. Of the surviving patients, only one had ischemic brain damage. In two cases a recurrent pulmonary embolism occurred after a follow-up of 16 years (mean follow-up 4.9 years). We conclude, that even with subtotal obstruction of the pulmonary artery, effective cardiopulmonary resuscitation with maintenance of uncompromised brain function is possible. In emergency situations, the decision to operate may be based only on clinical features without imaging diagnostic procedures.(ABSTRACT TRUNCATED AT 250 WORDS)