CirculationAHA SCIENTIFIC STATEMENTSurgical Management and Mechanical CirculatorySupport in High-Risk Pulmonary Embolisms:Historical Context,Current Status,and FutureDirections:A Scientific Statement From theAmerican Heart AssociationThis statement is endorsed by the American Association for Thoracic Surgery.This statement is endorsed by the Society of Thoracic Surgeons.The Society for Cardiovascular Angiography and Intervention affimms the value of this statement.Joshua B.Goldberg,MD,Chair;Jay Giri,MD,MPH,FAHA,Vice Chair;Taisei Kobayashi,MD;Marc Ruel MD,MPH,FRCSC,FAHA;Alexander J.C.Mittnacht,MD;Belinda Rivera-Lebron,MD,MS;Abe DeAnda Jr,MD,FAHA;John M.Moriarty,MD;Thomas E.MacGillivray,MD;on behalf of the American Heart AssociationCouncil on Cardiovascular Surgery and Anesthesia;Council on Arteriosclerosis,Thrombosis and Vascular Biology;Council onLifestyle and Cardiometabolic Health;and Council on Peripheral Vascular DiseaseABSTRACT:Acute pulmonary embolism is the third leading cause of cardiovascular death,with most pulmonary embolism-relatedmortality associated with acute right ventricular failure.Although there has recently been increased clinical attention to acutepulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams,mortalityof patients with pulmonaryembolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed.Becausehistorical data and practice patterns affect current consensus treatment recommendations,surgical embolectomy has largely beenrelegated to patients who have contraindications to other treatments or when other treatment modalities fail.Despite a selectionbias toward patients with greater illness,a growing body of literature describes the safety and efficacy of the surgical managementof acute pulmonary embolism,especially in the hemodynamically compromised population.The purpose of this document isto describe modern techniques,strategies,and outcomes of surgical embolectomy and venoarterial extracorporeal membraneoxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.Key Words:AHA Scientific Statements cardiopulmonary bypass cardiopulmonary resuscitationembolectomy■extracorporeal membrane oxygenation■heart failure■pulmonary embolism■survivalcute pulmonary embolisms (PEs)are common,present Furthermore,PE represents the third leading causeaffecting patients of all ages and comorbidity pro-of cardiovascular death in the United States,with associ-files.12 In 2016,there were an estimated 370000ated 30-day and 6-month all-cause mortality rates of 9.1%cases of PE in the United States,with PE hospital admis-and 19.6%,respectively,in the Medicare population.23sions tripling over the prior 2 decades.The estimated resid-It is estimated that up to 45%of PEs present with orual lifetime risk of developing a PE at 45 years of age isprogress to a more clinically severe presentation,includ-8.1%
