How do I manage a patient with suspected acute pulmonary embolism?

Editor - I read with great interest Sheares' excellent review article on the management of patients with suspected acute pulmonary embolism (PE) (Clin Med April 2011 pp 156–9). I would, however, like to comment on the author's recommendations regarding the treatment of high-risk PE, previously known as massive PE.

Sheares, citing the study of Jerjes-Sanchez et al¹ which states that thrombolysis improves survival in patients with high-risk PE. However, the author neglects to report the observations from the International Cooperative Pulmonary Embolism Registry.² Although admittedly somewhat counterintuitive, the findings of this landmark study were that thrombolysis did not reduce mortality or recurrence of PE at 90 days in high-risk PE.

Sheares confines the role of surgical embolectomy in high risk PE to patients who have failed thrombolysis or in whom thrombolysis is contraindicated. However, there is an emerging body of evidence supporting the use of primary embolectomy. Successful surgical embolectomy, using temporary cardiopulmonary bypass, was first reported by Denton Cooley 50 years ago.³ Thirty years later, Gulba et al compared the outcome of 13 patients with massive PE treated with surgical embolectomy and 24 such patients treated with thrombolysis.⁴ The surgically treated patients had a lower death rate as well as lower rates of bleeding and recurrence of PE. More recently, Fukuda et al have reported an operative mortality of only 5% in patients with massive PE undergoing emergent pulmonary embolectomy.⁵

Accordingly, primary surgical embolectomy should be considered favourably in centres with on-site cardiothoracic surgery. Given that the author's institution is an internationally acclaimed cardiothoracic centre, I would welcome her comments on her experience in this area.