Effectiveness of thrombolysis for massive pulmonary embolism with an atrial septal defect

Abstract

Thrombolysis is recommended for the treatment of massive pulmonary embolism (PE).1ESC Task Force for the Diagnosis and Management of Acute Pulmonary Embolism Guidelines on the diagnosis and management of acute pulmonary embolism.Eur Heart J. 2008; 29: 2276-2315Crossref PubMed Scopus (1898) Google Scholar We recently treated a 55-year-old man who presented with a three-week history of shortness of breath and coryzal symptoms following a transatlantic flight. Following admission he developed acute shortness of breath and a cold painful left hand. The patient was cardiovascularly stable but required tracheal intubation and ventilation for hypoxaemia and respiratory distress. Urgent computed tomographic pulmonary angiography (CTPA) showed bilateral proximal pulmonary artery filling defects consistent with a massive PE, a left subclavian artery filling defect and probable atrial septal defect (ASD). Anti-coagulation with intravenous (IV) heparin was started and the subclavian artery embolism removed surgically through a small axillary incision. The patient's cardiovascular status worsened after this and he required an IV adrenaline infusion and a single cycle (about 2 min) of cardiopulmonary resuscitation (CPR). Thrombolysis was also started with a 10 mg IV alteplase (recombinant tissue plasminogen activator) followed by a 45 mg h−1 infusion. The patient was too unstable (severely hypoxaemic and hypotensive) for transfer to a cardiothoracic surgery unit. In an attempt to improve a worsening situation, an inferior vena cava filter was inserted and through this a pigtail angiography catheter was passed into the pulmonary artery, with the intention of directing thrombolysis into the occluded pulmonary arteries. On initial placement the catheter was noted to be in the left atrium having passed through an ASD. Initial doses of contrast directly entered the aortic arch, with minimal flow into the pulmonary circulation and significant filling defects consistent with a saddle PE. This did not improve with directed thrombolysis injection close to the embolism. The patient continued to deteriorate and needed 15 min of CPR during the procedure for pulseless electrical activity (PEA). On return of spontaneous circulation, mechanical fragmentation, with rotational movements of the pigtail catheter and guide wire agitation, was also used to break up the embolism. The combination of CPR and mechanical fragmentation improved pulmonary artery blood flow (Fig. 1). The patient remained unstable and was transferred to the intensive care unit. Despite pulmonary artery reperfusion and multiple organ support including therapeutic hypothermia our patient died the next day.This case highlights a number of issues. Firstly, IV thrombolysis is probably ineffective in patients with ASD and massive PE as most blood flow is diverted into the systemic circulation through the ASD and not to the pulmonary arteries. Thrombolysis with an ASD may also result in systemic emboli to the brain causing an ischaemic stroke.2Stewart M.D. Gray H.H. Pulmonary embolism and venous thrombosis.Medicine. 2002; 30: 179-186Abstract Full Text PDF Google Scholar, 3Bracey T.S. Langrish C. Darby M. Soar J. Cerebral infarction following thrombolysis for massive pulmonary embolism.Resuscitation. 2006; 68: 135-137Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Our patient did not have a post mortem so we cannot rule this out. Early diagnostic echocardiography and surgical pulmonary embolectomy with ASD repair if immediately available may be a better treatment option in this setting. Secondly, the age of the embolic clot may determine how easily it lyses with thrombolysis.4Lapostolle F. Fabre D. Levasseur J. Adnet F. Role of pulmonary embolism in cardiac arrest after air travel: clot examination in survivors.Resuscitation. 2009; 80: 155-156Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Thirdly, fragmentation of embolism by guide wire or CPR can be effective at breaking up emboli in the pulmonary arteries. Finally, survival after massive PE with ASD is unfortunately poor.5Konstantinides S. Geibel A. Kasper W. et al.Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism.Circulation. 1998; 97: 1946-1951Crossref PubMed Scopus (330) Google ScholarConflict of interest statementThe authors have no relevant conflict of interest.The family of the patient have given consent for the publication of this letter. Thrombolysis is recommended for the treatment of massive pulmonary embolism (PE).1ESC Task Force for the Diagnosis and Management of Acute Pulmonary Embolism Guidelines on the diagnosis and management of acute pulmonary embolism.Eur Heart J. 2008; 29: 2276-2315Crossref PubMed Scopus (1898) Google Scholar We recently treated a 55-year-old man who presented with a three-week history of shortness of breath and coryzal symptoms following a transatlantic flight. Following admission he developed acute shortness of breath and a cold painful left hand. The patient was cardiovascularly stable but required tracheal intubation and ventilation for hypoxaemia and respiratory distress. Urgent computed tomographic pulmonary angiography (CTPA) showed bilateral proximal pulmonary artery filling defects consistent with a massive PE, a left subclavian artery filling defect and probable atrial septal defect (ASD). Anti-coagulation with intravenous (IV) heparin was started and the subclavian artery embolism removed surgically through a small axillary incision. The patient's cardiovascular status worsened after this and he required an IV adrenaline infusion and a single cycle (about 2 min) of cardiopulmonary resuscitation (CPR). Thrombolysis was also started with a 10 mg IV alteplase (recombinant tissue plasminogen activator) followed by a 45 mg h−1 infusion. The patient was too unstable (severely hypoxaemic and hypotensive) for transfer to a cardiothoracic surgery unit. In an attempt to improve a worsening situation, an inferior vena cava filter was inserted and through this a pigtail angiography catheter was passed into the pulmonary artery, with the intention of directing thrombolysis into the occluded pulmonary arteries. On initial placement the catheter was noted to be in the left atrium having passed through an ASD. Initial doses of contrast directly entered the aortic arch, with minimal flow into the pulmonary circulation and significant filling defects consistent with a saddle PE. This did not improve with directed thrombolysis injection close to the embolism. The patient continued to deteriorate and needed 15 min of CPR during the procedure for pulseless electrical activity (PEA). On return of spontaneous circulation, mechanical fragmentation, with rotational movements of the pigtail catheter and guide wire agitation, was also used to break up the embolism. The combination of CPR and mechanical fragmentation improved pulmonary artery blood flow (Fig. 1). The patient remained unstable and was transferred to the intensive care unit. Despite pulmonary artery reperfusion and multiple organ support including therapeutic hypothermia our patient died the next day. This case highlights a number of issues. Firstly, IV thrombolysis is probably ineffective in patients with ASD and massive PE as most blood flow is diverted into the systemic circulation through the ASD and not to the pulmonary arteries. Thrombolysis with an ASD may also result in systemic emboli to the brain causing an ischaemic stroke.2Stewart M.D. Gray H.H. Pulmonary embolism and venous thrombosis.Medicine. 2002; 30: 179-186Abstract Full Text PDF Google Scholar, 3Bracey T.S. Langrish C. Darby M. Soar J. Cerebral infarction following thrombolysis for massive pulmonary embolism.Resuscitation. 2006; 68: 135-137Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Our patient did not have a post mortem so we cannot rule this out. Early diagnostic echocardiography and surgical pulmonary embolectomy with ASD repair if immediately available may be a better treatment option in this setting. Secondly, the age of the embolic clot may determine how easily it lyses with thrombolysis.4Lapostolle F. Fabre D. Levasseur J. Adnet F. Role of pulmonary embolism in cardiac arrest after air travel: clot examination in survivors.Resuscitation. 2009; 80: 155-156Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar Thirdly, fragmentation of embolism by guide wire or CPR can be effective at breaking up emboli in the pulmonary arteries. Finally, survival after massive PE with ASD is unfortunately poor.5Konstantinides S. Geibel A. Kasper W. et al.Patent foramen ovale is an important predictor of adverse outcome in patients with major pulmonary embolism.Circulation. 1998; 97: 1946-1951Crossref PubMed Scopus (330) Google Scholar Conflict of interest statementThe authors have no relevant conflict of interest.The family of the patient have given consent for the publication of this letter. The authors have no relevant conflict of interest. The family of the patient have given consent for the publication of this letter.