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In this episode, the CardioNerds (Dr. Dinu Balanescu, Dr. Billy Joe Mullinax, and Dr. Akiva Rosenzveig) take a deep dive into the world of the surgical management of pulmonary embolism (PE) with faculty expert, Dr. Joshua Goldberg. We start from the pathophysiology of PE and its impact on right ventricular, and thereby left ventricular, hemodynamics. We then discuss the management of high-risk PE and where catheter-based therapies, surgical management and mechanical circulatory support via ECMO find their roles. Dr. Goldberg also provides a historical overview of the evolution of the surgical management of PE. We conclude by briefly discussing the management of chronic thromboembolic pulmonary hypertension (CTEPH) as a long-term complication of PE. Audio editing for this episode was performed by CardioNerds Intern, Dr. Julia Marques Fernandes. 

NOTE: this episode was recorded before the publication of the 2026 AHA/ACC Acute PE Guidelines.

Dr. Dinu Balanescu and Dr. Billy-Joe Mullinax are Co-chairs for the CardioNerds PE Series, developed in collaboration with the PERT Consortium.  

Enjoy this Circulation 2022 Paths to Discovery article to learn about the CardioNerds story, mission, and values.

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Pearls:

1. Beware of the RV death spiral. Hypotension occurs late in the acute PE pathophysiology as the LV function is preserved. A patient becomes hypotensive once all compensatory mechanisms have failed.
2. Don’t just treat the clot. Support the RV as well and think more seriously about ECMO.
3. One needs to be very careful intubating these patients, as sedating them will counteract many of the hemodynamic compensatory mechanisms and will lead to cardiac arrest. 
4. With the increasing role of catheter-based therapies, surgery’s role in acute PE is becoming more nuanced. Surgery is most useful in those patients with predominantly subacute clot, which is difficult to extract via catheter-based therapies.

Notes:

Notes: Notes drafted by Dr. Akiva Rosenzveig.

1. What is the hemodynamic consequences of high-risk PE and what is the Right ventricular (RV) “death spiral?”

Sudden increase in RV afterload which leads to RV volume and pressure overload which leads to neurohormonal activation, increased oxygen demand and RV ischemia, reduced RV contractility leading to reduced left ventricular (LV) preload and reduced cardiac output

2. What is the role of ECMO in acute PE?

We need to focus on not only treating the clot but supporting the RV concurrently. This is analogous to supporting the LV with mechanical circulatory support while also opening the culprit coronary lesion in acute myocardial infarction related cardiogenic shock (AMI-CS). The reason why High-risk/Massive PE has historically had poor outcomes may be because treatment modalities focused on treating the clot and not supporting the RV as well.

3. When is surgical embolectomy considered in the treatment of acute PE?

With the increased role of catheter-based therapies, the role of surgery is narrowing to a more nuanced patient population. Surgery should be considered when we don’t have other treatment options. It remains especially useful in more subacute clots where it is more difficult to extract with catheter-based interventions. In those cases, surgical pulmonary embolectomy can be useful as you have direct visualization of the pulmonary arteries and its branches.

4. What is the historical evolution of surgical management of PE?

In the early 1900’s, the Trendelenburg procedure was performed but had a very high mortality rate. This was because they waited for the patients to decompensate and then once the patient was peri-arrest, they would take them urgently to the operating room, snare the aorta and pulmonary artery and open the artery and remove the clot. By manipulating the PA in this way they detrimentally increased the RV afterload on an already failing RV. In the 1930’s, John Gibbon started working on developing cardiopulmonary bypass. Now, surgeons can put the patient on cardiopulmonary bypass and create incisions on both the left and right pulmonary arteries to extract the clot.

5. Can we be reassured if the patient does not have a saddle embolus?

Contrary to what we are used to hearing, the lack of a saddle PE shouldn’t be comforting. The more distal clot is more concerning as that’s where there is more significant flow resistance. The saddle embolus takes up a small proportion of the PA cross-sectional area and, therefore, the flow obstruction does not come from there.

References:

1. Goldberg JB, Spevack DM, Ahsan S, et al. Survival and Right Ventricular Function After Surgical Management of Acute Pulmonary Embolism. J Am Coll Cardiol. 2020;76(8):903-911. doi:10.1016/j.jacc.2020.06.065
2. Goldberg JB, Giri J, Kobayashi T, et al. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2023;147(9):e628-e647. doi:10.1161/CIR.0000000000001117
3. Delcroix M, Pepke-Zaba J, D’Armini AM, et al. Worldwide CTEPH Registry: Long-Term Outcomes With Pulmonary Endarterectomy, Balloon Pulmonary Angioplasty, and Medical Therapy. Circulation. 2024;150(17):1354-1365. doi:10.1161/CIRCULATIONAHA.124.068610