Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. iiino adohrccSurgery Cardiothoracic of Division MD Laan, Danuel author: Corresponding conference. work a This at consideration. Sincerely, presented and disclosures. been time financial your not relevant was for no work you have The Thank authors elsewhere. The published Funding: been of not Source has and Interest of Conflicts Article Original paper: of Type Embolectomy Pulmonary ‘ Invasive entitled manuscript Minimally our within find Please Surgery Cardiac of Journal Reviewers, and Editor(s) Dear highlights which 7/15/20 case-presentation a with with patients procedure additional two the and in to procedure. CPB MIPE made the central the we’ve with of performed augmentations adaptations. sternotomy have complications present over these we untoward preferentially herein results, it We no our employing revealing outcomes. of began 8-months excellent we publication to institution, initial our assess up Since at to embolectomy. follow-up MIPE adjunct hospital pulmonary mid-term the mean an a with of as of had success laparoscope days extraction complications, early degree post-operative valve, three With no 30 pulmonic of had 5mm, series the stay a this to of in of included distal use length patients and artery The artery, artery.2 pulmonary pulmonary pulmonary in the main the thoracotomy of of the clearance anterior closure of included 5cm primary which incision sided subsequent technique and left with our cannulation, identification clot venous described space, and We intercostal of arterial MIPE.1 3rd management femoral underwent the post-operative via who the (CPB) patients left streamlined bypass three a and cardiopulmonary described via operation peripheral publication (MIPE) the initial embolectomy refined pulmonary Our experience, invasive our patients. minimally expanded non-sternotomy have with we thoracotomy, experience mini initial our of publication Since Abstract 2020 16, July 4 3 2 1 Laan Danuel Minimally Non-Sternotomy Embolectomy procedure: Pulmonary Invasive new a on learned Lessons mr nvriySho fMedicine of School University Emory Hospital University Emory Beirut of University American University Emory 1 dy Assaf Edwyn , 2 onFallon John , esn ere naNwPoeue Non-Sternotomy Procedure: New a on Learned Lessons 3 n mrLattouf Omar and , .’ 1 4 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. uhr:Dne anMD Laan Danuel Authors: Surgery Cardiac of Journal Journal: Invasive Minimally Non-Sternotomy Embolectomy procedure: Pulmonary new a on learned Lessons Title: [email protected] email: 30308 GA Atlanta, 6D Suite NW St Peachtree 550 Medicine of School University Emory umnr moetm a die,adteptetpoeddt h prtn omugnl o MIPE. failure, for heart urgently right room acute operating of the evidence to proceeded burden, patient clot the extensive and common his left advised, on a was valvular revealed Based embolectomy and ultrasound echocardiogram pulmonary contractility thrombosis. duplex Transthoracic ventricular venous venous ng/L. extremities Left deep lower 620 Bilateral ventricle. femoral of right evaluation normal. (BNP) contractile grossly Laboratory was peptide poorly hypoxic. assessment natriuretic and and trans- B-type tachycardic enlarged and elevated persistently severely heparinized was revealed an was he patient right for arrival, The with notable Upon 1). noted was (Image institution. was phase our strain diastolic denied subsegmental to ventricle in ventricle and and right ferred left segmental of disorders than supple- into evidence larger clotting requiring saddle and Additionally, size ventricular a of hypoxic arteries bilaterally. demonstrated pulmonary and branches history main (CT) artery tachycardic family Tomography bilateral pulmonary normotensive, Computed no into was extending protocol- ongoing had he embolus (PE) exertion thy- He pulmonary Embolism presentation on partial Pulmonary On dyspnea and episode. new oxygen. laminectomy syncopal use. mental with C4-C5 a tobacco room kg/m2), emergency by or 44 local followed (BMI: alcohol his obesity days to morbid two presented of for prior history month with one male roidectomy old year 48 A Course: Pre-operative adaptations. made we’ve these sternotomy performed augmentations highlights presentation: have over present which we Case herein preferentially case-presentation We results, a it our outcomes. with employing excellent of procedure with began publication the patients we initial to additional Since two institution, in embolectomy. our MIPE pulmonary at the and procedure. MIPE stay the CPB of the of central artery. length complications of with untoward pulmonary hospital no success the mean pulmonary revealing of a early 8-months the clearance had to With of assess up complications, follow-up to closure post-operative mid-term adjunct no primary with an had days subsequent as series three with laparoscope this of degree in clot 30 included of patients 5mm, extraction The a valve, of sided use pulmonic left and cannulation, the artery, venous 3 to and the distal arterial in artery femoral thoracotomy via MIPE. anterior (CPB) underwent 5cm bypass who cardiopulmonary patients peripheral three included described streamlined publication and initial operation the Our refined patients. experience, our of embolectomy expanded management pulmonary have invasive post-operative we minimally thoracotomy, the mini non-sternotomy left with a experience via initial (MIPE) our of publication Since Embolectomy Pulmonary Invasive Introduction: Minimally Embolectomy, Pulmonary embolism, Pulmonary Keywords: Dvso fCritoai ugr,Dprmn fSrey mr nvriy tat,GA Lebanon Atlanta, University, Beirut, Emory Beirut; Surgery; of of University Department American Surgery, 2. Cardiothoracic of Division 1. 1 dy eeyAsfBS Assaf Jeremy Edwyn , rd necsa pc,ietfiainadicso ftemi pulmonary main the of incision and identification space, intercostal 2 2 onFlo MD Fallon John , 1 1 edsrbdortcnqewhich technique our described We mrLtofM PhD MD Lattouf Omar , 1 2 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. neirtoaooywscoe nsadr aho n eanlto olwdb earo eoa vessels The femoral space. of intercostal repair fourth by the followed decannulation into and points fashion en- entry depressed standard was separate mildly in through Hemostasis only closed placed was pre-operatively). to were thoracotomy improved function tubes anterior had systolic chest assessed function two depressed was however and severely function dilated sured with Cardiac remained (compared difficulty. ventricle function right without systolic bypass the cardiopulmonary and off TEE weaned via the venous then of inadequate was given repair patient pledgetted site, facilitated The surgical multiple technique the with from This bleeding closed the closure. was two-layer clear to arteriotomy running drainage. suction usual pulmonary applying the while the artery of large extracted, pulmonary instead We in were stitches, retrieval. advisable clots prolene vein). clot is 3-0 large and jugular TEE two exposure internal by of the right position hardship Once the undue accurate placed via this of prevent percutaneously guidance confirmation would second TEE and and a fluid patients cannulation under and of RA deployed percutaneous evidence inserted have the had dual cannula should into thus who we vein believe (SVC) 44 RA, mind, femoral cave of in common mid BMI vena this the with the With superior of via patient in flow (placed large scan. cannulas the this CT up venous in that and dual high echocardiography heart suspected preoperative the we being had empty on Furthermore, than cannula to based full. overload adequate venous rather relatively not ventricle the junction was right L/min that (RA)-IVC the 5 revealed atrial and images undrained right volume TEE the leaving intraoperative toward the back of from slipped review 5), each (Image and grasp inches clots, investigation 8 Nevertheless, large Further about trunks. two measuring clots. identify pulmonary each to clots left the able target and identify were the right we extract to the PA, and order main forceps the ring in endoscopic-type clear in incision with to artery employed requiring surgical thus suctioning pulmonary limited difficult vigorous main visualization 5 the with making approximately the significant with through in was bypass incision cardiopulmonary suctioning made PA full was the simultaneous Although from incision bleeding clots. one-inch the ongoing, was extract a L/min and point, forceps cardiopulmonary ring that insert seconds, At to 400 wires above order initiated. reached of have was placement to confirmed (CPB) 4). guided was bypass (Image TEE Time) Clotting ergonomics proper (Activated and enhanced ACT and needle the and vessel of Once each kinking insertion encountered, of line the fat dilation minimal facilitated subcutaneous by This with fully followed of cannuli incisions. was vessels layer and stab target patient deep separate 18- into through the The (wire-guided wire cannuli to guide artery the Due tunnel and fashion. to echocardiography) accomplished. standard decided cannula transesophageal was we a but venous by ) Medtronic rib, verified in cannula 25-French second Femoral-Flex atrium (wire-guided exposed French the right vein were of femoral the common portion into artery the a extending and of resect vein cannulation to and femoral prepared heparinized retraction also common simple were a right have We placed would The we inferior. incision exposure, it space facilitate required. pull intercostal better not second to to was PA order a such In hindsight main PA. In the preferentially main was in the 3). ventricle of suture right (Image isolation the PA that for of in better body inferior, been too the was than the incision rather our of that exposed edges realized to we the exposure, The direction to this parallel applied With exposure. in were facilitate opened sutures Traction to and 2). identified Artery. used pericardium. Tract–Pulmonary was (Image incised was Outflow tract space USA) Ventricular outflow Cor- intercostal Right 45040 ventricular AtriCure third the (Estech, OH right probe retractor the the Mason, (TEE) mini-mitral overlying Way in A echocardiography Innovation pericardium made difficult. transesophageal 7555 was visualization Headquarters a thoracotomy made porate fat anterior and endotracheal subcutaneous parasternal isolation lumen of Double 5cm lung inches neck. Two A left the extend achieve placed. and to hemithorax was left used the elevate was to intubation blade described. shoulder left previously the as neath was approach surgical Our Operation: 1 3 epstoe h ain uiewt upunder- bump a with supine patient the positioned We Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. xeinewt h IEw ffrtefloiga motn esn ere fe u nta description continued initial With our after recovery. learned enhanced lessons important for as allowing following the complications offer related we MIPE and embolectomy surgical the sternotomy in with advancement avoids an experience highlights it thoracotomy mini that left a in via MIPE the of days. complications, introduction bleeding 30 Our of within rates re-intervention therapy. lower for thrombolytic with requirement to associated and was compared wrote, embolectomy stroke, embolectomy previously rates pulmonary pulmonary we mortality surgical surgical As thrombolysis, 5-year that to PE. shown and massive have 30-day of pa- techniques similar treatment for surgical yields for improved or embolectomy highlighting contraindicated, surgical reports is of recent failed, utility has extended thrombolysis the collapse. when support cardiopulmonary only with extremis and in presenting PE tients mortality. massive cardiovascular for of 1 embolectomy cause POD surgical major a series on is our floor embolism care in Pulmonary general patient the fifth to the transferred and Discussion: 0, 3. PE, POD POD saddle on on massive extubated home for discharged was and MIPE procedure, underwent the Ultimately, who underwent days. tolerating patient total, several and recent ambulating for most oxygen, him supplemental Our immobilized or dialysis that requiring gout not severe diet. 19 of a POD extended recurrence on to discharged a due patient convalescence and the for coumadin. size, required a to patient were both transitioned stay, heparin, therapy ultimately and physical ICU to and sent and initiated exposure were mobilization was Given assay post-operative Argatroban discontinued, Extensive release was hemodialysis. serotonin Heparin pulmonary kidney of and further positive. acute session immunoglobulin were for non-oliguric safeguard (HIT) one and a requiring thrombocytopenia left thrombocytopenia as known hyperkalemia, by heparin-induced 3 a complicated coinciding POD had further patient on with RV was the placed injury course Notably, of was combination hospital assessment function. filter a His heart IVC echocardiographic on right until an embolism. and based assess and support weaned to pressure pre-operatively, catheter ventilatory was DVT venous the PA Flolan femoral and central a to of extubated. inotropic saturation, absence transport was oxygen given required to he function gas patient point prior venous The which central room at of operating 3 function. (POD) the ventricular day in right post-operative procedure. initiated support the was to of (Flolan) end ICU the Sodium second at Epoprostenol point a Aerosolized entry arteriotomy inserting artery pulmonary pulmonary the space, the about intercostal seal suture ap- course purse-string to technical second Post-operative sufficient cm our the was 2 modified which a in we incision placing incision and to experience, SVC, prior thoracotomy aforementioned the the anterior in cannula from the percutaneous learning making after by and proach case, artery. follow-up femoral a the In in pulses distal excellent resultant with Lcto fteatro hrctm hudb ae npeoeaieailadsgta mgn rather imaging sagittal and axial pre-operative on based be should thoracotomy anterior the of Location 1. Aporaevnu riaeo h er sipratt ucsflycmlt h prto.I the In operation. the complete successfully to important is heart the of drainage venous Appropriate 2. Aadteitra uua enit h V-Ajnto)t nuepoe eosdang which drainage venous proper ensure to the into junction) vein SVC-RA femoral the common into the vein via adequately jugular (placed successfully not drainage internal to drainage venous to arteriotomy the ventricle dual sufficient pulmonary and employ right the of RA now within the We capable suctioning causing robust not case. thus on the was factors, rely complete or to both surgery, us of right forced during combination the and into IVC or decompress up patient, the going large into vein the femoral back the in slipped from have placed catheter may drainage atrium venous single MIPE the 2 presented, subsequent case the The PA. via the performed surgery. of 3 been of have visualization the ease presented institution and and case exposure our exposure the at with In done difficulty procedures created interspace. and third inferior standardized too a to adhering than : 4 6 1,4 mrigdt rmorisiuinadothers and institution our from data Emerging 3 otciia udlnsol recommend only guidelines clinical Most nd necsa pc ihimproved with space intercostal rd 5,6 necsa pc was space intercostal oee,compared However, 1 . Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. etiua ielre hnlf etil ndatlcphase. right diastolic with in strain ventricle ventricle right left acute (B) than embolus after larger pulmonary recurrence saddle size (A) and ventricular showing: Survival tomography 2013. Computed J. to 1: Chikwe 1999 Image State, DH, York New Adams Surg in NN, Cardiovasc thrombolysis Egorova Thorac or embolectomy YP, versus J pulmonary Chiang with embolectomy treated S, surgical embolism Itagaki pulmonary embolism: T, pulmonary Lee Massive 6. al. et doi:10.1093/ejcts/ezs123 revisited? A, 94. be discussion Widmer indications management surgical A, and therapy–should Kadner diagnosis thrombolytic the T, on Aymard Guidelines Assistance. ESC 5. 2014 al. Thoracoscopic et embolism. G, pulmonary Agnelli acute A, With of Torbicki risk V., S and Konstantinides Embolectomy factors 4. risk Epidemiology, embolism. Pulmonary I: pulmonary nonthrombotic part Cardiol and Invasive Clin embolism, diagnosis presentation, Pulmonary clinical A. pathophysiology, Minimally stratification, Linhart V, B˘elohl´avek J. Dytrych J, 3. Invasive Fallon Minimally Non-Sternotomy with 180–184 doi:10.25373/CTSNET.11964948 Experience 15(2) Initial Vol. O. 2020, 2. Innovations Lattouf Assistance. D, Thoracoscopic Zapata with G, Embolectomy Luvika Pulmonary J, Fallon 1. cardiothoracic the of armamentarium the References: in tool valuable a MIPE. be the can of and description surgeon. reproducible original are our results to and augmentations operation several detailed have we summary, In Wiew aedmntae o aeo opiain,adzr otlt rmti rcdr in procedure this from mortality zero and complications, of rate low a demonstrated have we While approach. 6. multi-disciplinary based, team ven- a right requires recovering embolism the pulmonary massive aid with to patients adjunct of Care important purse- an 5. a is of Epoprostenol placement Aerosolized by of utilization facilitated Early easily more 4. much be can arteriotomy pulmonary the of Closure 3. u oteihrn iko adoumnr yas vns,w eiv htrcvr rmtesmall simpler and the easier from be recovery may that sternotomy believe standard we a embolus so, to pulmonary Even patients. compared for for surgery described bypass. right requires as recovering cardiopulmonary who thoracotomy of the patient anterior any risk aid mini with inherent to expected the support be to to inotropic due are and and ventilatory HIT) (prolonged AKI, heart, occur still did complications report previous our services. nephrology, work hematology, surgery, social vascular including and services therapy consulting physical involved patient this of care The technique, this employ to intend We tricle. incision. to prior closure. PA arteriotomy for planned forward, the here about suture string extraction. clot and visualization improved for allowed 031()1918 tp/wwnb.l.i.o/umd2903.Acse ac ,2020. 8, March Accessed http://www.ncbi.nlm.nih.gov/pubmed/23940438. 2013;18(2):129-138. . 1 h aepeetdhglgt htwiew eeal opromteMIPE, the perform to able were we while that highlights presented case the , 08153:0419.1.doi:10.1016/j.jtcvs.2017.07.074 2018;155(3):1084-1090.e12. . u er J Heart Eur 043(3:0338.doi:10.1093/eurheartj/ehu283 2014;35(43):3033-3080. . 5 u adohrcSurg Cardiothorac J Eur 2013;43(1):90-94; . 1 ebleethe believe We Exp Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. rce o A simdaeybnahadvsaie,hglgtn edfrhge niina 2 at incision higher for 3 need at highlighting place visualized, and in beneath retractor space. immediately mini-mitral is with PA, thoracotomy not tricle, left Anterior 3: Image 3 at incision of marking Pre-operative 2: Image rd necsa space. intercostal 6 rd necsa pc.Rgtven- Right space. intercostal nd intercostal Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. mg :Ploayeblcoyspecimen. embolectomy Pulmonary 5: Image bypass. cardiopulmonary peripheral for cannulation venous and arterial Femoral 4. Image 7 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. mg :Coe niinwt w riaecettbsi place in tubes chest drainage two with incision Closed 6: Image 8 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. 9 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. 10 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. 11 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. 12 Posted on Authorea 16 Jul 2020 | The copyright holder is the author/funder. All rights reserved. No reuse without permission. | https://doi.org/10.22541/au.159493373.38929453 | This a preprint and has not been peer reviewed. Data may be preliminary. 13