AHA to cardiothoracic surgeons: Get more involved in PE care

A scientific statement endorsed by the American Heart Association (AHA) has urged cardiothoracic surgeons to get more involved in the care of patients at high risk for pulmonary embolism (PE) – and to do it much earlier – to improve outcomes.

Experts also called for more data to clarify the best diagnosis and treatment options for this population.

Dr Joshua Goldberg from the Westchester Heart and Vascular Center, Valhalla, New York, US, who presented the statement at STS 2023, said there are lots of hurdles along the way, one of which is overcoming biases among surgeons and nonsurgeons alike.

“Talking about surgical embolectomy alone, there is bias among people that it is a very high-risk surgery and that patients do not do well,” he said. “Some lack understanding … in how and when surgery can be utilized.”

Another challenge is the availability of mechanical circulatory support. “Not every centre has it. On the other end, there is an explosion of transcatheter devices which work well but cannot fix everything. We must also divorce ourselves from the idea that minimally invasive is best, because it’s not always the best,” said Goldberg.

Other foci of the scientific statement are the surgical management of acute PE, new evidence for various surgical techniques, the potential shortcomings of the literature, and the impact on current practice. [Circulation 2023;147:e628–e647]

Why now, and how?

While surgeons historically “were seriously involved” in the treatment of PE, “the disease process has been taken out of our hands” with the advent of transcatheter therapies and other treatment options, commented co-moderator Dr Brent Keeling from the Emory University, Atlanta, Georgia, US, in a discussion following Goldberg’s presentation. “Why should surgeons seek to be more involved now, and how?,” he asked.

Goldberg explained that thrombolytics and catheter-directed therapies treat the clot, but they don’t ultimately treat the right ventricle (RV). “When RV is failing and you’re not supporting the RV, some patients are going to decompensate and die,” he emphasized. “It is akin to someone coming to you with a STEMI and cardiogenic shock, you’re not just going to open the LAD. The cardiologist is going to put in a balloon pump or an Impella [heart pump] because you must support the RV. It’s basically the same concept here.”

Goldberg shared that at his institution, half of PE patients are being treated with transcatheter therapy and the rest with surgery or extracorporeal membrane oxygenation (ECMO).

“But the real factor is that in the current paradigm, this explosion of transcatheter therapies is not improving survival,” he noted. “Recurrent high-risk trials that are coming out do not really include an adequate surgical comparative cohort, so this is something we need to do to. Is our profession going to take over PE? No, but at least we should be actively involved.”

ECMO can be life saving

Dr Roberto Lorusso from Maastricht University Medical Centre, Maastricht, Netherlands said many in the cardiology community viewed ECMO as “too aggressive,” when many patients go into cardiac arrest because they are not treated with ECMO.

Goldberg said this highlights a problem with the current risk stratification criteria for patients. “Once a patient is classified as high-risk, or haemodynamically unstable, that patient is about to arrest,” he said. “So, we need to pick up those patients before they decompensate … we need to intervene earlier.” Early ECMO is the safest way to treat these patients, he added.

Goldberg also noted that many patients go for surgery too late. “Surgical outcomes would have been better if they were operated on earlier.”