1. Long-term Benefits of Surgical Pulmonary Embolectomy for Acute Pulmonary Embolus on Right Ventricular Function Brent Keeling MD 1, Bradley G. Leshnower MD 1, Yi Lasajanak MSPH 2, Jose Binongo PhD 2, Robert A. Guyton MD 1, Michael E. Halkos MD 1, Vinod H. Thourani MD 1, Omar M Lattouf MD 1 1 Clinical Research Unit Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery Emory University School of Medicine, Atlanta, Georgia 2 Department of Biostatistics, Rollins School of Public Health Emory University School of Medicine, Atlanta, Georgia

2. No disclosures

3. Background Increasing focus on pulmonary embolus (PE)- related mortality and improvements in care for patients with PE Has not translated into an increase in volumes of surgical pulmonary embolectomy (SPE) Concern over outcomes, durability

4. 108 patients with massive pulmonary emboli in the ICOPER registry (>2000 PE patients), 3 underwent SPE In a recent analysis of the Nationwide Inpatient Sample, researchers showed an inpatient mortality rate of 27.2% Background Kucher N, et al. Massive pulmonary embolism. Circulation 2006. Kilic A, et al. Nationwide outcomes of surgical embolectomy for acute pulmonary embolism. The Journal of thoracic and cardiovascular surgery 2013.

5. Purpose To review our institutional experience with SPE and detail current results To document the mid-term echocardiographic follow-up of patients who underwent SPE in order to prove that the immediate postoperative improvements in right ventricular function were durable

6. Retrospective review of local STS database from 1998-2014 Patients with chronic pulmonary thromboembolic disease were excluded Unadjusted outcomes were reported, and quantitative comparisons were made of short- and mid-term echo data Echo follow-up was at the discretion of the treating physician Methods

7. Results 44 patients included for analysis 9 massive (HD instability requiring vasopressors), remaining 35 submassive (RV dysfunction) Majority female (56.8%)

8. Results All (n=44)Massive (n=9) Submassive (n=35) MeanDiff/ OR95%CIp-value Age51.6 ± 16.150.6 ± 14.851.2 ± 16.60.62(- 11.6, 12.9 )0.92 Female25 (56.8%)6 (66.7%)19 (54.3%)1.57 (0.34,7.20 )0.56 Ejection fraction59.6±6.760.0±11.559.5±5.2-0.51 (-6.4,5.3 )0.86 Hypertension28 (63.6%)4 (44.4%)24 (68.6%)0.38 (0.09,1.71 )0.21 NYHA class 3-418 (40.9%)5 (55.6%)13 (37.1%)2.04 (0.46,8.95 )0.35 Diabetes8 (18.2%)08 (22.9%)0.17 (0.01,3.77 )0.26 Chronic Lung Disease _ None36 (81.8%)6(66.7%)30 (85.7%) 0.13 _ Mild6 (13.6%)3(33.3%)3 (8.6%) _ Moderate000 _ Severe2 (4.6%)02 (5.7%) Previous myocardial infarction10 (22.7%)2 (22.2%)8 (22.9%)1.08 (0.20,5.89 )0.93 Previous CVA4 (9.1%)1 (11.1%)3 (8.6%)1.64 (0.19,13.99 )0.65 Previous Cardiac Surgery1 (2.3%)0 (0.0%)1 (2.9%)1.21 (0.04,37.21 )0.91 Cerebrovascular disease4 (9.1%)1 (11.1%)3 (8.6%)1.64 (0.19,13.99 )0.65 Mean preoperative serum creatinine1.1 ± 0.60.9 ± 0.31.2 ± 0.70.24 (-0.3,0.7 )0.33 Chronic renal insufficiency1 (2.3%)0 (0.0%)1 (2.9%)1.21 (0.04,37.21 )0.91 Dyslipidemia10 (22.7%)1 (11.1%)9 (25.7%)0.49 (0.07,3.56 )0.48 History of smoking4 (9.1%)4 (44.4%)058.09 (2.56,1316.4 )0.01 Immunosuppressive therapy5 (11.4%)0 (0.0%)5 (14.3%)0.29 (0.01,6.72 )0.44 Body Mass Index30.5 ± 11.329.8 ± 5.830.7 ± 12.30.88 (-8.2,9.9 )0.85

9. Results All (n=44) Massive (n=9) Submassive (n=35) MeanDiff / OR 95%CIp-value Aortic cross clamp (minutes) 47.4±40.4 59.0±41. 3 43.9±40.7-15.1(-58.4,28.3 )0.48 Cardiopulmonary Bypass Time 68.0±40.2 82.8±54. 9 64.1±35.4-18.7(-48.9,11.6 )0.22 Concomitant valve procedures 3 (6.8%)1 (11.1%)2 (5.7%)2.36(0.25,22.35 )0.45 Concomitant CABG2 (4.5%)1 (11.1%)1 (2.9%)4.06(0.34,47.94 )0.27 Intraoperative IABP insertion 5 (11.4%)1 (11.1%)4 (11.4%)1.24(0.15,9.95 )0.84

10. Results All (n=44) Massive (n=9) Submassive (n=35)OR95%CI p- value 30-day mortality 1 (2.3%) 0 1 (2.9%)1.21(0.04,37.21 )0.91 Stroke 0 0 0 Renal failure 4 (9.1) 0 4 (11.4%)0.37(0.02, 8.69)0.54 New Dialysis 1 (2.3%) 0 1 (2.9%)1.21(0.04,37.21 )0.91 Prolonged Ventilation 17 (38.6%) 3 (33.3%) 14 (40.0%)0.8(0.17,3.68 )0.77 Re-Exploration for Hemorrhage 2 (4.5) 0 2 (5.7%)0.71(0.03, 18.53)0.83

11. Results Preoperative (n=21) Postoperative (n=21) p-value ≥ Moderate ventricular dysfunction 17 (81.0%)9 (42.9%)0.01 ≥ Moderate tricuspid regurgitation 6 (28.6%)1 (4.8%)0.03 Pulmonary Artery Systolic Pressure (mm/Hg) 51.2 ± 21.636.6 ± 10.1 0.21 Tricuspid Valve Regurgitant Velocity (m/s) 3.1 ± 0.82.8 ± 0.70.20

12. Mid-term Echo Results Preoperative Value (n=21) Mid-term Value (n=12) P Value ≥ Moderate ventricular dysfunction 17 (81.0%)1 (8.3%)<0.0001 ≥ Moderate tricuspid regurgitation 6 (28.6%)0 (0)0.0005 Pulmonary Artery Systolic Pressure (mm/Hg) 51.2 ± 21.637.2 ± 14.20.01 Tricuspid Valve Regurgitant Velocity (m/s) 3.1 ± 0.82.4 ± 0.70.03

13. SPE can be performed safely with a low in- hospital mortality for acute PE The beneficial effects of SPE on right ventricular hemodynamics are immediate and profound Improvements in RV hemodynamics seen acutely after SPE persist at mid-term follow- up Conclusions

14. SPE should likely be performed more often as part of a multi- disciplinary PE strategy Conclusions

15. Long-term Benefits of Surgical Pulmonary Embolectomy for Acute Pulmonary Embolus on Right Ventricular Function Brent Keeling MD 1, Bradley G. Leshnower MD 1, Yi Lasajanak MSPH 2, Jose Binongo PhD 2, Robert A. Guyton MD 1, Michael E. Halkos MD 1, Vinod H. Thourani MD 1, Omar M Lattouf MD 1 1 Clinical Research Unit Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery Emory University School of Medicine, Atlanta, Georgia 2 Department of Biostatistics, Rollins School of Public Health Emory University School of Medicine, Atlanta, Georgia