Earlier, More-Active Surgeon Involvement Needed in PE Care: AHA

SAN DIEGO, CA—Cardiothoracic surgeons should be involved earlier in the treatment process for patients with high-risk pulmonary embolism (PE) in order to potentially improve outcomes, according to a scientific statement endorsed by the American Heart Association (AHA).

This isn’t the first time experts have called for more surgical involvement in pulmonary embolism response teams (PERTs), but Joshua B. Goldberg, MD (Westchester Heart and Vascular Center, Valhalla, NY), who presented the statement during the Society of Thoracic Surgeons (STS) annual meeting this week, told TCTMD that many hurdles have stood in the way.

“One of them is overcoming biases among surgeons and nonsurgeons alike in that just talking about surgical embolectomy, there is a bias among a lot of people that it is a very high-risk surgery and patients do not do well,” he said. “Some of that is a lack of understanding . . . in how and when it can be utilized. And another challenge is the availability of mechanical circulatory support. Not every center has it. The third challenge is there is an explosion of transcatheter devices which work really well but can't fix everything, and we will have to divorce ourselves from the idea that minimally invasive is best because it is not always.”

Is our profession going to take over PE? No. But at least be really actively involved. Joshua B. Goldberg

The goal of the statement, published online Monday in Circulation, was to highlight the surgical literature in this space, which Goldberg said includes the “most robust understanding of high-risk patients [and] is missed within a lot of the academic papers, meta-analyses, and so on.”

In a discussion following Goldberg’s presentation, co-moderator Brent Keeling, MD (Emory University, Atlanta, GA), commented that while surgeons historically “were very involved” in the treatment of patients with PE, “this disease process has been taken out of our hands” with the advent of transcatheter therapies and other treatment options. He asked: why should surgeons seek to be more involved now, and how?

Goldberg emphasized that while thrombolytics and catheter-directed therapies treat the clot, they don’t ultimately treat the right ventricle. “When you get into a situation in which the RV is failing and you're not supporting the RV, a section of those patients are going to decompensate and die,” he explained. “It is akin to someone coming to you with a STEMI and cardiogenic shock, you are not just going to open the LAD. The cardiologist is going to put in a balloon pump or Impella because at that point you have to support the RV. It's the same concept as here.”

At his institution, where he explained that the surgeons have aggressively sought to be involved in PE care, Goldberg said about half of PE patients are 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 be really actively involved.”

Early ECMO Encouraged

In the statement, Goldberg and a multidisciplinary team of colleagues outline the history of surgical involvement and mechanical circulatory support for PE as well as common PE pathophysiology. The authors highlight the dangers of putting these patients on anesthesia, which can sometimes lead to cardiac arrest. While different techniques have been developed to mitigate this risk, they note that using cardiopulmonary bypass or VA-ECMO virtually eliminates it, but acknowledge that more research is needed in this area.

They also outline the variety of ways in which modern surgical embolectomy is performed, noting that “the timing and conduct of cardiopulmonary bypass and the surgical approach may affect the observed differences in outcomes.”

Goldberg stressed the variety of time points in which surgical embolectomy is used among institutions, from primary to salvage therapy. This has an effect on surgical participation on PERTs.

It's incumbent on us to put data out there. The more data, the better. Brent Keeling

“One criticism of some of the PERT teams are that surgeons . . . only become involved when the PERT team says: ‘You need to do surgery,’ rather than it being part of the process in evaluating these patients,” he said. “And some of that falls on the surgeons because they are not investing as well, but I think that is where the PERT team, this type of document, and this understanding into the future research will really benefit these PERT teams and they can have a more-holistic understanding of the treatments in the disease process.”

Audience member Roberto Lorusso, MD, PhD (Maastricht University Medical Centre, the Netherlands), recalled a “really impressively bad experience” serving as the sole surgeon on the writing committee for the 2019 European Society of Cardiology PE guidelines.

“I was trying to explain that 9% of the patients who are in cardiac arrest are due to pulmonary embolism and they were saying that the diagnosis [should be made with a] CT scan,” he said. “The issue is also about how you handle these patients even in the pathway of diagnosis and treatment, because if you take a patient to the cath lab, then it could be also easier to treat the patient with transcatheter immediately.”

Further, Lorusso said ECMO is viewed as “too aggressive” by many in the cardiology community, but, in his opinion, many patients end up in cardiac arrest because they aren’t treated with ECMO.

Goldberg replied that this example highlights a problem with the current risk stratification criteria for these patients. “Once you become classified high-risk, once you are hemodynamically unstable, those patients are really about to arrest with this pathophysiology,” he said. “So there needs to be a refined identifier to pick up these patients before they decompensate so you can intervene earlier.”

Early ECMO is the “safest way” to treat these patients, Goldberg continued, because “then you have time to figure out, ‘Ok, am I going to operate on this patient? Am I going to transcatheter?’”

More Data Needed

But ultimately what’s needed is more research, especially in high-risk patients, Goldberg argued. “You talk to one person who said [PE patients] should all get tPA. You talk to another person who says they should all get transcatheter. You talk to a surgeon, they say they should all get ECMO or surgery. The truth is that everyone is right in certain situations and we as a community do not really know,” he said. “There are a lot of opinions and not much data.”

“It's incumbent on us to put data out there. The more data, the better,” Keeling agreed.

What is clear, Goldberg added, is that many patients who do end up undergoing surgery are being operated on “very late in the process.” It’s likely that surgical outcomes would be even better and more effective if patients were sent to the OR earlier, he said.