PMID- 29730125
OWN - NLM
STAT- MEDLINE
DCOM- 20190919
LR  - 20190919
IS  - 1097-685X (Electronic)
IS  - 0022-5223 (Linking)
VI  - 156
IP  - 2
DP  - 2018 Aug
TI  - Triage and optimization: A new paradigm in the treatment of massive pulmonary 
      embolism.
PG  - 672-681
LID - S0022-5223(18)30931-0 [pii]
LID - 10.1016/j.jtcvs.2018.02.107 [doi]
AB  - BACKGROUND: Massive pulmonary embolism (PE) remains a highly fatal condition. 
      Although venoarterial extracorporeal membrane oxygenation (VA-ECMO) and surgical 
      pulmonary embolectomy in the management of massive PE have been reported 
      previously, the outcomes remain less than ideal. We hypothesized that the 
      institution of a protocolized approach of triage and optimization using VA-ECMO 
      would result in improved outcomes compared with historical surgical management. 
      METHODS: All patients with a massive PE referred to the cardiac surgery service 
      between 2010 and 2017 were retrospectively reviewed. Patients were stratified by 
      treatment strategy: historical control versus the protocolized approach. In the 
      historical control group, the primary intervention was surgical pulmonary 
      embolectomy. In the protocol approach group, patients were treated based on an 
      algorithmic approach using VA-ECMO. The primary outcome was 1-year survival. 
      RESULTS: A total of 56 patients (control, n = 27; protocol, n = 29) were 
      identified. All 27 patients in the historical control group underwent surgical 
      pulmonary embolectomy, whereas 2 of 29 patients in the protocol approach group 
      were deemed appropriate for direct surgical pulmonary embolectomy. The remaining 
      27 patients were placed on VA-ECMO. In the protocol approach group, 15 of 29 
      patients were treated with anticoagulation alone and 14 patients ultimately 
      required surgical pulmonary embolectomy. One-year survival was significantly 
      lower in the historical control group compared with the protocol approach group 
      (73% vs 96%; P = .02), with no deaths occurring after surgical pulmonary 
      embolectomy in the protocol approach group. CONCLUSIONS: A protocolized strategy 
      involving the aggressive institution of VA-ECMO appears to be an effective method 
      to triage and optimize patients with massive PE to recovery or intervention. 
      Implementation of this strategy rather than an aggressive surgical approach may 
      reduce the mortality associated with massive PE.
CI  - Copyright (c) 2018 The American Association for Thoracic Surgery. Published by 
      Elsevier Inc. All rights reserved.
FAU - Pasrija, Chetan
AU  - Pasrija C
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md. Electronic address: cpasrija@smail.umaryland.edu.
FAU - Shah, Aakash
AU  - Shah A
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - George, Praveen
AU  - George P
AD  - Department of Medicine, University of Maryland School of Medicine, Baltimore, Md.
FAU - Kronfli, Anthony
AU  - Kronfli A
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Raithel, Maxwell
AU  - Raithel M
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Boulos, Francesca
AU  - Boulos F
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Ghoreishi, Mehrdad
AU  - Ghoreishi M
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Bittle, Gregory J
AU  - Bittle GJ
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Mazzeffi, Michael A
AU  - Mazzeffi MA
AD  - Department of Anesthesiology, University of Maryland School of Medicine, 
      Baltimore, Md.
FAU - Rubinson, Lewis
AU  - Rubinson L
AD  - Shock Trauma Critical Care Unit, University of Maryland School of Medicine, 
      Baltimore, Md.
FAU - Gammie, James S
AU  - Gammie JS
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Griffith, Bartley P
AU  - Griffith BP
AD  - Division of Cardiac Surgery, Department of Surgery, University of Maryland School 
      of Medicine, Baltimore, Md.
FAU - Kon, Zachary N
AU  - Kon ZN
AD  - Department of Cardiothoracic Surgery, New York University Langone Health, New 
      York, NY.
LA  - eng
PT  - Journal Article
DEP - 20180407
PL  - United States
TA  - J Thorac Cardiovasc Surg
JT  - The Journal of thoracic and cardiovascular surgery
JID - 0376343
SB  - IM
CIN - J Thorac Cardiovasc Surg. 2018 Aug;156(2):682-683. PMID: 29655547
CIN - J Thorac Cardiovasc Surg. 2018 Aug;156(2):684. PMID: 29895381
MH  - Adult
MH  - Aged
MH  - Embolectomy/statistics & numerical data
MH  - Extracorporeal Membrane Oxygenation/statistics & numerical data
MH  - Female
MH  - Humans
MH  - Male
MH  - Middle Aged
MH  - Pulmonary Embolism/*epidemiology/*therapy
MH  - Retrospective Studies
MH  - Risk Factors
MH  - Thrombolytic Therapy/statistics & numerical data
MH  - Treatment Outcome
MH  - Triage
OTO - NOTNLM
OT  - massive pulmonary embolism
OT  - surgical pulmonary embolectomy
OT  - veno-arterial extracorporeal membrane oxygenation
EDAT- 2018/05/08 06:00
MHDA- 2019/09/20 06:00
CRDT- 2018/05/07 06:00
PHST- 2017/05/04 00:00 [received]
PHST- 2018/02/16 00:00 [revised]
PHST- 2018/02/25 00:00 [accepted]
PHST- 2018/05/08 06:00 [pubmed]
PHST- 2019/09/20 06:00 [medline]
PHST- 2018/05/07 06:00 [entrez]
AID - S0022-5223(18)30931-0 [pii]
AID - 10.1016/j.jtcvs.2018.02.107 [doi]
PST - ppublish
SO  - J Thorac Cardiovasc Surg. 2018 Aug;156(2):672-681. doi: 
      10.1016/j.jtcvs.2018.02.107. Epub 2018 Apr 7.