Massive Pulmonary Hemorrhage After Pulmonary Endarterectomy: Updated Outcomes of a Standardized Management Protocol over 14 Years

Background: Massive pulmonary hemorrhage is a life-threatening complication of pulmonary endarterectomy (PEA) with limited evidence to guide standardized management. Methods: We retrospectively evaluated consecutive PEA procedures performed at a high-volume center and analyzed the incidence, perioperative characteristics, management strategies, and early outcomes of patients who developed massive pulmonary hemorrhage. Results: Among 1123 patients who underwent PEA, massive pulmonary hemorrhage occurred in 51 (4.54%) and developed intraoperatively after completion of PEA and separation from total circulatory arrest. Primary suturing achieved hemostasis in 12 patients (23.5%), and bronchial isolation was applied in 18 (35.3%). Local adjuncts included intraoperative bronchial clamping in 1 patient (2.0%) and biological glue occlusion in 2 (3.9%). Extracorporeal membrane oxygenation (ECMO) was required in 25 patients (49.0%), initiated intraoperatively in 22 and postoperatively in 3. Overall in-hospital mortality was 41.2%, while 30 patients (58.8%) survived to hospital discharge; among survivors, mean hospital length of stay was 16.1 ± 6.8 days. Conclusions: Massive pulmonary hemorrhage after PEA remains associated with substantial early mortality and resource utilization; a stepwise institutional algorithm combining bronchoscopy-guided localization, targeted airway/surgical control, and timely ECMO support may help standardize management in this critical setting.