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.............................................................................. was no difference between the two types of reperfusion treatment regarding 30 day mortality (15 and 13%, respectively), but thrombolysis was associated with a higher risk of stroke and reintervention at 30 days. No difference was found in terms of 5 year actuarial survival, but thrombolytic therapy was associated with a higher rate of recurrent PE requiring readmission compared with surgery (7.9 vs. 2.8%). However, the two treatments were not randomly allocated in this observational retrospective study, and the patients referred for surgery may have been selected. An analysis of the Society of Thoracic Surgery Database with multicentre data collection, including 214 patients submitted for surgical embolectomy for high- (n = 38) or intermediate-risk (n = 176) PE, revealed an in-hospital mortality rate of 12%, with the worst outcome (32%) in the group experiencing pre-operative cardiac arrest.299

Recent experience appears to support combining ECMO with surgical embolectomy, particularly in patients with high-risk PE with or without the need for cardiopulmonary resuscitation. Among patients who presented with intermediate-risk PE (n = 28), high-risk PE without cardiac arrest (n = 18), and PE with cardiac arrest (n = 9), the in-hospital and 1 year survival rates were 93 and 91%, respectively.300

6.4 Multidisciplinary pulmonary

embolism teams The concept of multidisciplinary rapid-response teams for the management of ‘severe’ (high-risk and selected cases of intermediaterisk) PE emerged in the USA, with increasing acceptance by the medical community and implementation in hospitals in Europe and worldwide. Set-up of PE response teams (PERTs) is encouraged, as they address the needs of modern systems-based healthcare.301 A PERT brings together a team of specialists from different disciplines including, for example, cardiology, pulmonology, haematology, vascular medicine, anaesthesiology/intensive care, cardiothoracic surgery, and (interventional) radiology. The team convenes in real time (face-toface or via web conference) to enhance clinical decision-making. This allows the formulation of a treatment plan and facilitates its immediate implementation.301 The exact composition and operating mode of a PERT are not fixed, depending on the resources and expertise available in each hospital for the management of acute PE.

6.5 Vena cava filters

The aim of vena cava interruption is to mechanically prevent venous clots from reaching the pulmonary circulation. Most devices in current use are inserted percutaneously and can be retrieved after several weeks or months, or left in place over the long-term, if needed. Potential indications include VTE and absolute contraindication to anticoagulant treatment, recurrent PE despite adequate anticoagulation, and primary prophylaxis in patients with a high risk of VTE. Other potential indications for filter placement, including freefloating thrombi, have not been confirmed in patients without contraindications to therapeutic anticoagulation. Only two phase III randomized trials have compared anticoagulation with or without vena cava interruption in patients with proximal DVT, with or without associated PE.302304 In the Prevention of Recurrent Pulmonary Embolism by Vena Cava Interruption (PREPIC) study, insertion of a permanent vena cava filter was associated with a significant reduction in the risk of recurrent PE and a significant increase in the risk of DVT, without a significant difference in the risk of recurrent VTE or death.303,304

The PREPIC-2 trial randomized 399 patients with PE and venous thrombosis to receive anticoagulant treatment, with or without a retrievable vena cava filter. In this study, the rate of recurrent VTE was low in both groups and did not differ between groups.302 A systematic review and meta-analysis of published reports on the efficacy and safety of vena cava filters included 11 studies, with a total of 2055 patients who received a filter vs. 2149 controls.305 Vena cava filter placement was associated with a 50% decrease in the incidence of PE and an 70% increase in the risk of DVT over time. Neither all-cause mortality nor PE-related mortality differed between patients with or without filter placement. The broad indication for placement of a venous filter in patients with recent (<1 month) proximal DVT and an absolute contraindication to anticoagulant treatment is based mainly on the perceived high risk of recurrent PE in this setting, and the lack of other treatment options. Complications associated with vena cava filters are common and can be serious. A systematic literature review revealed penetration of the venous wall in 1699 (19%) of 9002 procedures; of these cases, 19% showed adjacent organ involvement and >_8% were symptomatic.306 Lethal complications were rare (only two cases), but 5% of the patients required major interventions such as surgical removal of the filter, endovascular stent placement or embolization, endovascu-

6.6 Recommendations for acute-phase treatment of high-risk pulmonary embolisma

Recommendations Classb Levelc

It is recommended that anticoagulation with UFH, including a weight-adjusted bolus injection, be initiated without delay in patients with high-risk PE. I C Systemic thrombolytic therapy is recommended for high-risk PE. 282 I B Surgical pulmonary embolectomy is recommended for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed.d 281 I C Percutaneous catheter-directed treatment should be considered for patients with highrisk PE, in whom thrombolysis is contraindicated or has failed.d IIa C Norepinephrine and/or dobutamine should be considered in patients with high-risk PE. IIa C ECMO may be considered, in combination with surgical embolectomy or catheter-directed treatment, in patients with PE and refractory circulatory collapse or cardiac arrest.d 252 IIb C

ECMO = extracorporeal membrane oxygenation; PE = pulmonary embolism; UFH = unfractionated heparin. aSee Table 4 for definition of high-risk PE. After haemodynamic stabilization of the patient, continue with anticoagulation treatment as in intermediate- or low-risk PE (section 6.7). bClass of recommendation. cLevel of evidence. dIf appropriate expertise and resources are available on-site. Downloaded from academic.oup.com/eurheartj/article/41/4/543/5556136 by guest on 07 October 2026