Which is the best reperfusion therapy in patients with acute pulmonary embolism?

Abstract

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Pulmonary embolism (PE) represents the third most common cause of cardiovascular death. Reperfusion therapy is recommended in patients with high-risk PE, while in intermediate-risk PE is controversial but could be indicated in those patients with a higher risk of hemodynamic instability and death due to right ventricular failure. Currently, the recommended reperfusion strategy in this group of patients is systemic thrombolysis. Catheter directed therapy can also be considered with less clinical evidence. Purpose Determine the safety and efficacy of catheter directed therapy compared with systemic thrombolysis in patients with acute PE who required reperfusion therapy. Methods A single-center retrospective observational cohort study was carried out in patients who were admitted for PE in a University Hospital from 2008 to 2021. Patients with intermediate-high and high risk PE, according to ESC guidelines, who underwent reperfusion therapies based on an institutional clinical practice guideline were included. Reperfusion was recommended in high-risk patients and those with intermediate-high risk who presented right ventricular dilatation associated with at least two of the following: heart rate ≥ 100bpm, systolic blood pressure ≤100mmHg or lactic acid ≥2mmol / L. Patients with surgical thrombectomy were excluded. In-hospital outcomes and 30-day follow-up between both strategies were analyzed. Results Catheter directed therapy was performed in 66% and systemic thrombolysis in 34% of the population. The prevalence of hemodynamic instability was 28.1% and in-hospital mortality was 25%. Baseline characteristics of both populations were similar and there were no differences in the location of the thrombi between both groups. In-hospital mortality and major bleeding rates between catheter directed therapy and systemic thrombolysis were similar between both strategies (27.2% vs. 23.8%) and (9.0% vs. 4.7%) respectively. Both treatment groups presented a significant reduction in right ventricular diameters after reperfusion. Only catheter directed therapy showed an improvement in right ventricular function and a reduction in pulmonary pressures. Conclusion In this population no differences were observed in terms of safety and efficacy between both reperfusion therapies. Both strategies significantly reduced right ventricular diameters after reperfusion but only catheter directed therapy improved right ventricular function and reduced pulmonary pressures after 30 days which could have implications in a lower incidence of chronic thromboembolic pulmonary hypertension.