Surgery over lysis in acute pulmonary embolism – let us challenge the guidelines

We have read with great interest the article prepared by Pruszczyk and Konstantinides published in “Kardiologia Polska” (Kardiol Pol, Polish Heart Journal) [1]. This paper presents strategies for patients with acute pulmonary embolism (PE) depending on the risk of unfavourable prognosis.
Acute PE is still a medical challenge. According to the Silesian Heart and Vessels Database SILCARD from 2006–2014, the number of patients with acute PE diagnosis increased almost 2.5-fold in the 8-year follow-up. Hospital mortality in 2006 and 2014 were 17.6% and 14.4%, respectively, while the 12-month mortality fluctuates around 30% among patients with acute PE.
Looking at these results, a review of the management of patients with acute pulmonary embolism is needed.
We would like to discuss with the statement contained in the above-cited article about the treatment of haemodynamically unstable patients with acute pulmonary embolism. The authors suggest that systemic thrombolysis should be an in-device method for most high-risk patients, leaving invasive treatments such as transcutaneous catheter therapy and surgical pulmonary embolectomy (SPE) as a second-line therapy, when thrombolysis is contraindicated or failed. That statement is consistent with ESC guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) from 2019.
It is common knowledge that in acute PE, pressure overload resulting in right ventricular failure is considered a major cause of death. In haemodynamically unstable individuals, rapid and complete revascularization of pulmonary circulation is of the utmost importance.
Based on the experience of the Silesian Centre of Heart Disease, in this group of patients rapid SPE is a better treatment option than systemic thrombolysis.
Recently, a few publications comparing systemic thrombolysis and surgical pulmonary embolectomy have been reported.
Lee et al. [2] performed a retrospective comparison of 2111 adults with acute PE, who underwent either thrombolysis or SPE as a first-line therapy. The authors proved that there were no statistical differences in the 30-day and 5-year mortality in the groups of patients treated with surgical embolectomy or systemic thrombolysis (13.2% vs. 15.2%; p = 0.62; OR = 1.12; 95% CI: 0.72–1.73 and 13.9% vs. 27.6%; HR = 1.11; 95% CI: 0.83–1.49, respectively). However, systemic thrombolysis significantly...


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