Management of acute massive pulmonary embolism: Is surgical embolectomy inferior to thrombolysis?

Background Although current guidelines for pulmonary embolism (PE) treatment recommend surgical embolectomy when thrombolysis is contraindicated or has failed, their clinical outcomes rarely have been compared directly. Methods After excluding patients aged under 18 years and those with submassive or non-massive PE, 45 consecutive patients (median age, 68 years; 62% female; 31% experienced cardiac arrest before PE treatment onset; 33% had cancer diagnosis history; and 29% received extracorporeal membrane oxygenation [ECMO]) who underwent only thrombolysis (TL group; n = 19) or surgical embolectomy (SE group; n = 26, including 4 who had failed thrombolysis) for acute massive PE from 2000 to 2013 at Samsung Medical Center were enrolled to assess cardiac mortality as primary outcome. Results Median follow-up duration was 17.2 months. In the SE group, significantly higher proportions of patients had recent surgery and ECMO. Overall 30-day all-cause mortality rate was 24% (n = 11), without significant difference between the SE (15%) and TL (37%) groups (P = 0.098); however, cardiac mortality rate was significantly higher in the TL than SE group (Log rank P = 0.023). TL was an independent multivariate predictor of cardiac death (P = 0.03). Conclusion In this small retrospective single center experience, surgical embolectomy is associated with lower cardiac mortality risk than thrombolysis, which might render it first-line treatment option for acute massive PE for patients without life-limiting comorbidities.