Advanced Treatment of Submassive Pulmonary Embolism by a Multidisciplinary Response Team
Sameer A. Hirji, MD1, Ahmed A. Kolkailah, MD1, Gregory Piazza, MD, MS2, Julius I. Ejiofor, MD, MPH1, Aaron B. Waxman, MD, PHD3, Fernando Ramirez Del Val, MD, MPH1, Jiyae Lee, BS1, Siobhan McGurk, BS1, James M. McCabe, MD4, Samuel Z. Goldhaber, MD2, Sary F. Aranki, MD1, Prem S. Shekar, MD1, Piotr Sobieszczyk, MD2, Tsuyoshi Kaneko, MD1.
1Division of Cardiac Surgery; 2Division of Cardiovascular Medicine; 3Division of Pulmonary Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; 4Division of Cardiology, University of Washington, Seattle, Washington.
Background: Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction carries a high risk of mortality, and is classified as submassive PE. We report the results of a multidisciplinary PE Response Team approach for treatment of submassive PE with surgical pulmonary embolectomy and catheter-directed thrombolysis (CDT).
Methods: Between October 1999 and May 2015, 133 submassive PE patients underwent advanced treatment (71 pulmonary embolectomy and 62 CDT). Our multidisciplinary team consists of cardiologists, pulmonologists, cardiovascular imaging specialists, cardiac surgeons, and interventional cardiologists, who recommend, on a case-by-case basis, the appropriate advanced treatment strategy. The EkoSonic ultrasound-facilitated thrombolysis system (EKOS) was used for CDT.
Results: Mean age of submassive PE patients was 57.3 years, and 36.8% were females. PE risk factors included previous deep venous thrombosis (46.6%), immobility (36.1%), recent surgery (30.8%), and cancer (22.6%). The frequency of pulmonary embolectomy remained unchanged after incorporating the EKOS procedure into our treatment algorithm. Any bleeding was observed in 6 CDT patients and 1 pulmonary embolectomy patient. Postoperative stroke was observed in one pulmonary embolectomy patient. Follow-up echocardiography was available for 61% of the overall cohort, of whom, 76.5% had no residual moderate or severe RV dysfunction.
Conclusion: Pulmonary embolectomy and CDT are important advanced treatment options for these high-risk PE patients. Careful, multidisciplinary evaluation and access to both treatment options can maximize clinical benefit. 
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