Michelle Lyons, a 33-year-old social studies teacher, recalls the first time she noticed something was wrong. As she played with her 3-year-old daughter, she struggled to catch her breath. Since RSV and flu were going around, she thought it might be the beginning of a respiratory illness. By the evening, she felt better and went to sleep.
But the breathless feeling continued, so Michelle sought care at the Emergency Department at Atrium Health Wake Forest Baptist Medical Center, where test results revealed she had a large blood clot, known as a pulmonary embolism, in her lung. In addition, she had two blood clots in her heart. Dr. Bart Imielski, cardiothoracic surgeon and professor of surgical sciences with Atrium Health Wake Forest Baptist, evaluated her in light of this potentially life-threatening condition.
As her condition stabilized, Imielski recommended initial medical management and prescribed anticlotting medication to dissolve the clots. At that point, surgery would be a last resort. Performing a thrombectomy to remove some of the lung clot carried the risk of showering small emboli (portions of the blood clot) further into her lung.
After six months on the medication, Michelle still didn’t feel well. She couldn’t pick up her daughter without feeling out of breath, and a follow-up CT scan showed the blood clots were still in her lung and heart. Imielski diagnosed Michelle with chronic thromboembolism pulmonary hypertension, meaning the blood clot in her lung was stuck in her pulmonary artery.
“As the embolism grows, it creates a lot of resistance to blood flow in the lungs,” explains Imielski. “It's a serious problem because it can eventually cause heart failure.”
About 5% of patients with pulmonary embolisms will not reabsorb or dissolve them. While it's a relatively small patient population, it can be very debilitating, especially for young patients with busy schedules. Since Michelle’s quality of life continued to be affected, Imielski recommended surgery to remove the clots.
Open-heart surgery
Imielski’s team scheduled Michelle’s surgery during her summer break. Using open-heart surgery, he performed a pulmonary thromboembolectomy to remove the blood clots.
“It's a complex procedure that requires periodically stopping the patient’s blood flow throughout the body,” Imielski explains. “We put the patient on cardiopulmonary bypass, which is a machine that takes over the patient’s breathing and blood circulation. This allows us to access the area where the pulmonary arteries are located and cut them open.”
When Imielski entered Michelle’s chest and saw the lung clot, he noticed that it had grown into the wall of the pulmonary artery. He had to surgically remove the clot from the lung artery. While peeling it away, Imielski got to a point within the dependent portion of the pulmonary artery where the blood was pulling and there was still some clot remaining. The only way he could go deeper to finish removing the clot was by shutting off the bypass machine. This allows the team to work through the surgery without blood.
Imielski’s surgical team cooled Michelle’s body to 18 degrees Celsius for about 15 minutes and then turned off the pump. Cooling the patient’s body allows the brain to survive brief periods without blood flow. Once the surgical team gets as far down into the pulmonary arteries as possible, they turn the bypass pump back on. After the remaining portions of the clot were removed, they warmed Michelle’s body back to normal.
Once the clot in the lung was removed, Imielski removed the clots in Michelle’s heart.
Unique surgical program
According to Imielski, pulmonary thromboembolectomy is an established procedure. However, only about 12 centers in the U.S. perform the surgery.
“Most medical programs don't train surgeons on this procedure,” notes Imielski. “Most surgeons in the U.S. who do this procedure were trained directly or indirectly through Dr. Michael Madani, cardiothoracic surgeon with the University of California San Diego. I was lucky enough that one of my mentors at Northwestern University trained with him, so I was able to learn his technique.”
In addition, there are few programs established to evaluate patients with chronic thromboembolism pulmonary hypertension. Most primary care doctors are unfamiliar with the condition and its treatment.
A chronic thromboembolism pulmonary hypertension program requires close collaboration between experts in CT surgery and pulmonary medicine. Additionally, the surgery can only be performed at experienced centers with advanced technologies, such as extracorporeal membrane oxygenation (ECMO), which are needed to manage rare but potentially known complications of the procedure. Wake Forest Baptist offers the collaboration and supportive technologies required to provide safe, effective cardiothoracic surgery.
Confidence in care
“I went to the right hospital at the right time,” says Michelle. “They knew what it was and came up with a plan of action immediately. I’m thankful this great hospital is located just five minutes from home and in the same city as my family.”
Michelle also felt confident in Imielski’s ability to deliver a positive outcome.
“He made me feel very comfortable with the procedure,” Michelle says. “He explained his background and training and helped me understand everything involved.”
Michelle says the nurses, especially those in the ICU, were fantastic.
“It’s a lot to process and go through,” Michelle says, “They were kind, understanding and supportive. They were willing to sit and listen to me express my feelings.”
Results and recovery
Following surgery, Michelle’s pulmonary artery pressure dropped by half and back into the normal range, leaving her feeling great from the moment she woke up. Her shortness of breath was gone. She just needed time to recover from open-heart surgery.
Michelle spent about five days in the hospital, followed by continued rest at home. Imielski encouraged her to walk every day to foster healing. She was unable to do any heavy lifting or driving for the first month of her recovery. During the second month, she was allowed to slowly resume her normal activities.
Back to normal and breathing easy
Nine months after surgery, Michelle’s life has returned to normal. She’s able to walk around and teach in the classroom with ease. She can keep up with her young daughter without struggling to breathe.
Michelle takes a low-dose blood thinner to maintain her health. Her care team is trying to figure out why she developed the blood clots. Her pregnancy in 2020, case of COVID-19 in 2021 and years of taking the birth control pill may have created the “perfect storm” for forming blood clots.
Michelle is looking forward to supporting her family’s fundraiser for the American Lung Association’s Fight For Air Climb in the spring. This event promotes lung disease awareness and involves climbing stairs with friends and family in a fun, positive atmosphere.
“When you do the stair climb, you support people with lung disease who are fighting for every breath,” says Michelle. “I know firsthand what it’s like to struggle to breathe, so I’m glad I feel well enough to support those still struggling.”
Learn more about cardiothoracic surgery at Wake Forest Baptist.
