Acute pulmonary embolectomy. a contemporary approach

lar diseases that coexists in a large proportion of these patients) such as use of beta-blockers, control of blood pressure, lipid lowering therapy, smoking cessation, etc. were either utilized in very few patients or were not reported in the two trials. Thus, this lack of survival advantage of early-surgery seen in both these studies is even more relevant if viewed in the light of these inadequate medical therapies in these patients. These two studies suggests that surveillance with imaging at 6 monthly intervals is safe and is associated with no increased risk of rupture in patients with small abdominal aortic aneurysm (4.0 –5.4 cm in diameter), especially if accompanied with aggressive medical treatment to lower blood pressure and cholesterol, a beta-blocker to reduce dP/dt and smoking cessation. The results should not be applied to patients in whom compliance with follow-up and lifestyle modification is not likely. RM

considered, the initial approach requires alerting cardiology, pulmonary medicine/critical care, radiology, cardiovascular surgery and anesthesia. Temporary support with ECMO or venoarterial cardiopulmonary bypass can be life saving and bide time. Pulmonary angiography with its immutable delays and risk is not generally necessary for the diagnosis or treatment of hemodynamically significant pulmonary emboli. MR

Hospital Volume and Surgical Mortality in the United States Birkmeyer JD, Siewers AE, Finlayson EVA, et al. N Engl J Med 2002;346:1128 –37. Study Question: What is the relation between hospital volume of surgical procedures (cardiovascular procedures) and surgical mortality? Methods: Information from the national Medicare claims database and the Nationwide Inpatient Sample was utilized to examine the mortality (in-hospital or within 30 days) associated with six different types of cardiovascular procedures between 1994 and 1999 in relation to hospital volume (total number of procedures per year) using regression techniques. Hospitals were ranked in order of increasing total procedure volume, and then five volume groups were defined by the selection of whole number cut-off points of annual volume that most closely sorted the patients into five groups of equal size (quintiles). Results: Mortality for all types of cardiovascular procedures decreased as volume increased. Thus, the adjusted odds ratios (95% confidence interval) for mortality for various cardiovascular procedures for the low volume, medium volume, high volume, very high volume (referent ⫽ very low volume hospital with OR ⫽ 1) were as follows: coronary artery bypass graft surgery 0.92 (0.86 – 0.95), 0.89 (0.83– 0.95), 0.84 (0.78 – 0.90), respectively; aortic valve replacement 0.92 (0.85– 0.99), 0.91 (0.84 – 0.99), 0.84 (0.77– 0.92), 0.75 (0.66 – 0.86), respectively; mitral valve replacement 0.91 (0.83–1.00), 0.86 (0.78 – 0.96), 0.79 (0.71– 0.88), 0.74 (0.65– 0.84), respectively; carotid endarterectomy 0.95 (0.88 –1.02), 0.91 (0.84 – 0.99), 0.88 (0.81– 0.95, 0.88 (0.80 – 0.96), respectively; lower-extremity bypass 0.94 (0.89 –1.00), 0.90 (0.85– 0.97), 0.94 (0.87– 1.01), 0.81 (0.74 – 0.88), respectively; and elective repair of abdominal aneurysm 0.79 (0.73– 0.86), 0.70 (0.64 – 0.76), 0.71 (0.65– 0.78), 0.58 (0.53– 0.65), respectively. The relative importance of volume varied markedly according to the type of procedure. Conclusions: Medicare patients undergoing selected cardiovascular surgeries can significantly reduce their risk of operative mortality by selecting a high-volume hospital. Perspective: Since quality ratings are unavailable for many cardiovascular procedures and most patients needing cardiovascular procedures are unaware of the outcomes of such surgery in a nearby hospital, this study suggests that

Acute Pulmonary Embolectomy. A Contemporary Approach Aklog L, Williams CS, Byrne JG, Goldhaber SZ. Circulation 2002; 105:1416 –9. Study Question: What is the utility of embolectomy for acute pulmonary embolus (PE) in the thrombolytic era? Methods: An observational study of acute pulmonary embolectomy in 29 patients enrolled based on verification of PE by lung scan or CT in 24 and pulmonary angiography in 5. The indication for surgery was a contraindication to (17) or failed thrombolytic therapy (2), massive PE (4), right atrial mass (4) and hemodynamic instability (2). Surgery was a median sternotomy with heparin for cardiopulmonary bypass using normothermia and simple forceps extraction. TEE was used to assess the need for removal of RA masses and closure of a PFO. Results: The average age was 61 years (range 34 – 86 years) and 26 had moderate-to-severe right ventricular (RV) dysfunction by echo. All had large central emboli. Eleven of the 29 underwent concomitant procedures: 3 closure of PFO, 7 excision of RA thrombi and 1 left atrial myxoma. IVC filter was inserted preoperatively in 24 and intraoperatively in 4. Postoperative RV stunning was common and required inotropic support. 89% survived surgery and were alive at 1 month. Deaths occurred and were associated with the very old, failure to place an IVC filter and a ventricular fibrillation arrest. At a median 10-month follow-up, one patient had died of cancer. Conclusion: The high survival rate of 89% can be attributed to surgical technique, rapid diagnosis and triage with careful patient selection. Perspective: The results are from a center of excellence in pulmonary thromboembolism with special expertise and interest and should not be generalized. Surgical colleagues willing to undertake the risk of an acute pulmonary artery thrombectomy are hard to find. When a massive PE is

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