High-risk Acute Pulmonary Embolism Research Articles

Ultrasound-assisted catheter-directed thrombolysis versus surgical pulmonary embolectomy for intermediate-high or high-risk pulmonary embolism: a randomized phase II non-inferiority trial.

We hypothesized that ultrasound-assisted thrombolysis (USAT) is non-inferior to surgical pulmonary embolectomy (SPE) to improve right ventricular (RV) function in patients with acute pulmonary embolism (PE). In a single-centre, non-inferiority trial, we randomly assigned 27 patients with intermediate-high or high-risk acute PE to undergo either USAT or SPE stratified by PE risk. Primary and secondary outcomes were the baseline-to-72-h difference in right-to-left ventricular (RV/LV) ratio and the Qanadli pulmonary occlusion score, respectively, by contrast-enhanced chest-computed tomography assessed by a blinded CoreLab. The trial was prematurely terminated due to slow enrolment. Mean age was 62.6 (SD 12.4) years, 26% were women, and 15% had high-risk PE. Mean change in RV/LV ratio was -0.34 (95% CI -0.50 to -0.18) in the USAT and -0.53 (95% CI -0.68 to -0.38) in the SPE group (mean difference: 0.152; 95% CI 0.032-0.271; Pnon-inferiority = 0.80; Psuperiority = 0.013). Mean change in Qanadli pulmonary occlusion score was -7.23 (95% CI -9.58 to -4.88) in the USAT and -11.36 (95% CI -15.27 to -7.44) in the SPE group (mean difference: 5.00; 95% CI 0.44-9.56, P = 0.032). Clinical and functional outcomes were similar between the 2 groups up to 12 months. In patients with intermediate-high and high-risk acute PE, USAT was not non-inferior when compared with SPE in reducing RV/LV ratio within the first 72 h. In a post hoc superiority analysis, SPE resulted in greater improvement of RV overload and reduction of thrombus burden.

Experience of urgent surgical thrombolectomy of high-risk acute massive pulmonary embolism under parallel cardiopulmonary bypass: a case report

Massive acute pulmonary embolism is a rare and life-threatening condition that cardiac surgeons may encounter in their clinical practice. Although systemic thrombolysis is often prescribed in critically ill patients to improve pulmonary perfusion and reduce right ventricular afterload, surgical treatment is an objective alternative when thrombolytic therapy is ineffective or impossible. Aim. Determining the expediency of pulmonary thromboembolectomy in the case of unavailability or impossibility of systemic thrombolysis to optimize treatment protocols for patients with high-risk pulmonary embolism accompanied by hemodynamic instability. Materials and methods. We present clinical cases of patients with high-risk pulmonary embolism as determined by multispiral computed tomography with Miller index determination. In both cases, the condition of the patients upon admission was critical, due to rapidly progressing hemodynamic instability, severe pulmonary hypertension, and right ventricular failure. Results. The patients were urgently brought to the operating room with severe desaturation, bradycardia, in a state of medical sedation and with pronounced hypotension. Taking into account the patients’ severe condition and the results of the tomography, we performed emergency pulmonary thromboembolectomy using a modified surgical technique using cardiopulmonary bypass without deep hypothermia or transverse aorta clamping. Conclusions. The complete clinical remission resulting from the clinical observations described in this study demonstrates the feasibility of performing open pulmonary thromboembolectomy in combination with anticoagulant therapy in patients with high-risk pulmonary embolism accompanied by hemodynamic instability based on clinical diagnosis in specific individual cases.

Referral and outcomes of mechanical thrombectomy for pulmonary embolism - a single-centre experience

Abstract Funding Acknowledgements None. Introduction Acute pulmonary embolism (PE) is a significant cause of morbidity and mortality, and percutaneous catheter-based treatments have emerged as an effective treatment option alongside thrombolysis. However, data concerning long-term outcomes are scarce. Methods All patients referred to a tertiary centre for pulmonary angiography with the intent to perform mechanical thrombectomy in the context of acute PE between January 2016 and August 2023 were retrospectively included and clinical data and outcomes were collected. Results Fifty-two patients (58% female; mean age 66±18 years) were referred to pulmonary angiography in the setting of acute PE, of whom 40 patients (77%) underwent continuous aspiration mechanical thrombectomy with an overall success rate of 70%. Twenty-eight percent of patients had bilateral thrombus. Thirty-two patients had intermediate-high risk or high-risk PE, and the mean Pulmonary Embolism Severity Index (PESI) was 146 points. Thirteen patients (25%) underwent thrombolysis prior to angiography, while 15 patients (28%) had an absolute or relative contraindication for thrombolysis. Ventilation/perfusion scans were performed in ten patients (19%) during the follow-up period, of whom five patients (10%) had evidence of residual illness, with no significant differences between the thrombectomy and non-thrombectomy groups (p=0.8). The overall mortality rate over the complete follow-up period was 39%, while 25% of patients died within 48 hours of the procedure. Predictors of mortality on univariate analysis included older age (HR 1.06 [95% CI 1.00-1.11, p = 0.03]), history of chronic obstructive pulmonary disease (HR 3.88 [95% CI 1.41-10.69, p = 0.01]), history of previous deep vein thrombosis or PE (HR 3.40 [95% CI 1.34-8.63, p = 0.01]), thrombolysis prior to referral for mechanical thrombectomy (HR 5.94 [95% CI 1.93-18.26, p <0.01), shock or haemodynamic instability (HR 8.50 [95% CI 2.44-29,52, p <0.01]) and resuscitated cardiac arrest (HR 5.98 [95% CI 2.34-15.30, p <0.01]). On Cox multivariate analysis, the presence of shock or haemodynamic instability was a predictor of increased mortality (HR 5.23 [95% CI 1.12-24.3, p = 0.04]). Conclusions Intermediate and high risk acute PE is a clinical entity with a high morbidity and mortality rate regardless of treatment strategy, particularly during the index hospitalization and in patients with shock or haemodynamic instability.

F-40 | Hemodynamic Outcomes of Percutaneous Pulmonary Thrombectomy in Intermediate High Risk Acute Pulmonary Embolism : A Single Center Analysis

F-40 | Hemodynamic Outcomes of Percutaneous Pulmonary Thrombectomy in Intermediate High Risk Acute Pulmonary Embolism : A Single Center Analysis

Systemic Immune-Inflammation Index as a Potential Biomarker for Predicting Acute Pulmonary Embolism: A Systematic Review.

Acute pulmonary embolism (APE) is a life-threatening condition with a high mortality rate. The pathophysiology involves various complex processes. The systemic immune-inflammatory index (SII) is a well-known biomarker that reflects the intricate balance between pro-inflammatory and anti-inflammatory immune components. In this systematic review, we aim to determine the significance of SII as a potential biomarker for APE. We utilized PubMed, ProQuest, EBSCOHost, and Google Scholar to search for articles. We assessed bias risk using the Newcastle Ottawa Scale (NOS). The outcomes we examined included in-hospital and long-term mortality, the severity of APE, and the sensitivity and specificity of the SII in predicting APE. Four studies, involving 2,038 patients, were included for analysis. These studies discuss the use of SII in predicting APE severity, APE mortality, high-risk APE, and the occurrence of APE. SII demonstrates significant results in predicting each of these variables. Furthermore, each study establishes different SII cut-off values. Specifically, a cut-off of 1161 predicts massive APE events with a sensitivity of 91% and a specificity of 90%. A cut-off of >1235.35 differentiates high-risk APE with a sensitivity of 87.32% and a specificity of 68.85%. A cut-off of >1111x109 predicts overall mortality with a sensitivity of 72% and a specificity of 51%. Finally, a cut-off at 1839.91 predicts APE events with a sensitivity of 75.8% and a specificity of 61.9%. The SII can be employed as a potential new biomarker to predict outcomes in APE patients, particularly the occurrence, severity, and mortality of APE.

Ultrasound-Facilitated, Catheter-Directed Thrombolysis for Acute Pulmonary Embolism.

Acute pulmonary embolism (APE) poses a significant risk to patient health, with treatment options varying in efficacy and safety. Ultrasound-facilitated catheter-directed thrombolysis (USCDT) has emerged as a potential alternative to conventional catheter-directed thrombolysis (CDT) for patients with intermediate to high-risk APE. This study aimed to compare the efficacy and safety of USCDT versus conventional CDT in patients with intermediate to high-risk APE. This observational retrospective study was conducted at the Armed Forces Hospital, Al-Hada, Taif, the Kingdom of Saudi Arabia (KSA), on 135 patients diagnosed with APE and treated with either USCDT or CDT (58 underwent CDT, while 77 underwent USCDT). The primary efficacy outcome was the change in the right ventricle to the left ventricle (RV/LV) diameter ratio.Secondary outcomes included changes in pulmonary artery systolic pressure and the Miller angiographic obstruction index score. Safety outcomes focused on major bleeding events. Both USCDT and CDT significantly reduced RV/LV diameter ratio (from 1.35 ± 0.14 to 1.05 ± 0.17, P < 0.001) and systolic pulmonary artery pressure (SPAP) (from 55 ± 7 mmHg to 38 ± 7 mmHg, P < 0.001) at 48- and 12-hours post-procedure, respectively, with no significant differences between treatments. However, USCDT was associated with a significantly lower rate of major bleeding events compared to CDT (0% vs. 3.4%, P = 0.008). Multivariate logistic regression analysis revealed that USCDT was associated with a 71.9% risk reduction of bleeding (OR = 0.281, 95% CI = 0.126 - 0.627, P = 0.002). USCDT is a safe and effective alternative to CDT for the treatment of intermediate to high-risk APE, as it significantly reduces the risk of major bleeding.

SPO2/FIO2 and early echocardiographic findings on presentation to guide high risk and intermediate-high risk acute pulmonary embolism patients

SPO2/FIO2 and early echocardiographic findings on presentation to guide high risk and intermediate-high risk acute pulmonary embolism patients

Фактори несприятливого прогнозу в жінок із високим ризиком гострої тромбоемболії легеневої артерії

The aim – to determine the risk factors of an unfavorable prognosis in patients with pulmonary embolism (PE) depending on gender.Materials and methods. A retrospective analysis of the data of 635 patients with a verified diagnosis of PE according to multispiral computed tomographic angiography (MSCT-angiography) of pulmonary vessels and/or according to autopsy results, who were consecutively hospitalized at Kharkiv City Clinical Hospital No. 8 for the period from January 1, 2017 to January 1, 2023. Patients were divided into two groups: IA group included patients with high-risk acute PE who were discharged from the hospital, IВ group – patients with high-risk acute PE who died during the hospital period. Clinical and anamnestic, laboratory and instrumental indicators were analyzed, statistical processing of data depending on gender was carried out.Results and discussion. When analyzing the obtained data, it was established that in the group of deceased patients with a high risk there was probably a higher proportion of women (72 % at p=0.014). Deceased males had more severe clinical manifestations than deceased females, as evidenced by significantly lower SpO2 values (p=0.022) and larger right ventricular dimensions on echocardiography (p=0.036). In turn, such a risk factor of PE as obesity was more common in women than in men (61.1 % vs. 28.6 % at p=0.039). In order to determine independent factors associated with in-hospital mortality in high-risk PE patients in women, we conducted uni- and multifactorial logistic regression analysis of the influence of the studied factors. Since the small number of deceased men in the sample (n=14) does not allow us to draw reasonable conclusions, the analysis of factors affecting mortality is given only for the group of women. Factors associated with in-hospital death were the presence of arterial hypertension in the anamnesis (p=0.043), a decrease in systolic blood pressure (p=0.0003) in the acute period, and the localization of a thrombus at the bifurcation of the pulmonary arteries (p=0.012). After performing the regression analysis, we derived a formula for individual prediction of the risk of in-hospital death for gender with high-risk PE. Using the ROC analysis, it was established that the sensitivity of the obtained prognostic formula is 75.0 %; specificity – 83.9 (area under the ROC curve 0.867; 95 % confidence interval 0.762–0.938, p&lt;0.0001). The formula developed by us includes available general clinical indicators and allows specifying the individual risk of in-hospital mortality for female patients with high-risk PE.Conclusions. The results of a comparative analysis of two subgroups of patients with high-risk PE who died, depending on gender, showed that men were more likely to have lower SpO2 values and larger right ventricular sizes according to echocardiography. In turn, such risk factors as obesity were more common in women than in men. According to multivariate logistic regression analysis, additional independent factors that are associated with the development of death during the hospital period in women with high-risk PE are the presence of arterial hypertension in the anamnesis, a decrease in systolic blood pressure in the acute period, and the localization of a thrombus at the bifurcation of the pulmonary arteriesof. Proposed formula, according to which Y&gt;0.5 establishes an additional high risk of in-hospital death in women with high-risk PE.

Effectiveness and safety of catheter-directed thrombolysis for acute pulmonary embolism: a systematic review and meta-analysis

Abstract Background Catheter-directed thrombolysis (CDT) can accelerate relief of the right ventricle overload secondary to acute pulmonary embolism (PE). The effectiveness and safety of CDT, also in relation to dose, duration, and different devices, are still a matter of debate. Purpose We conducted a systematic review and meta-analysis to assess effectiveness and safety of CDT for intermediate- and high-risk acute PE. Methods We systematically searched PubMed, Web of Science and CENTRAL (inception-December 2022) and selected randomized controlled trials (RCTs), observational studies, and epidemiological analysis (DRG-based, nationwide studies), focusing on standard CDT (sCDT) vs. ultrasound-assisted catheter-directed thrombolysis (USAT) for intermediate- and high-risk acute PE, according to European Society of Cardiology definition. We obtained pooled estimate rates for bleeding (intracranial and major), in-hospital/30-day fatality rate, and estimated the early improvement of several hemodynamic parameters (i.e. right/left ventricle [RV/LV] ratio, pulmonary artery pressure [PAP]) and long-term course. Results Overall, 58 studies with 37,496 patients (mean age 60 years) were included. The pooled intracranial bleeding rate was 0.15% (95%CI: 0-0.58%) in trials and cohort studies, and 0.87% (95%CI: 0.44-1.42%) in epidemiological studies; Fig. 1. Randomized trials comparing CDT vs. anticoagulation alone reported neither intracranial nor fatal bleeding events. In trials and cohort studies, higher rates of major bleedings were observed with longer (4.5%; 95%CI: 2.4-7.1%) vs. shorter (0.7%, 95%CI: 0-2.2%) treatment duration (p=0.01), irrespective of the dose; Fig. 2. Longer CDT regimens were associated with a high fatality rate of 2.8% (95%CI: 1.5-4.2%) vs. 0.1% (95%CI: 0-1.1%) with shorter CDT treatment (&amp;lt;0.01), disregarding the lytic dose; Fig. 2. All early hemodynamic and radiological outcomes assessed in available studies improve after CDT regardless of dose, duration, and type of device. However, data on the long-term course of PE after CDT has been rarely reported in literature. Conclusions The available evidence supports the notion that CDT strategies may represent a safe option for reversing right ventricular dysfunction due to acute PE. Overall, the reported rate of intracranial bleeding was below 1%. Patients exposed to longer CDT regimens had a higher incidence of major bleeding and fatality. Randomised trials with clinical outcomes are necessary to truly establish optimal patient selection and CDT protocol.Prevalence of intracranial bleedingOutcomes in RCTs and cohort studies

Effectiveness and safety of catheter-directed thrombolysis for pulmonary embolism in key patient subgroups: results of an individual patient level analysis

Abstract Background The effectiveness of catheter-directed thrombolysis (CDT) for acute pulmonary embolism (PE) has been rarely investigated in subgroups of patients at a higher risk of complications. Furthermore, this group of patients has been excluded from prior and ongoing phase 3 trials with CDT. Purpose To assess the efficacy and safety of catheter-directed thrombolysis for pulmonary embolism among specific patient subpopulations. Material and methods We conducted an individual patient-level analysis of patient data from 16 cohort studies and randomized trials of CDT for intermediate- and high-risk acute PE. Studies were identified on the basis of a systematic review of the literature. We focused on early clinical outcomes, including haemodynamic decompensation, intracranial bleeding, major bleeding, and death, as well as on the changes in the mean pulmonary artery pressure (mPAP) before and after CDT. We predefined three subgroups of at-risk patients: (i) older age (i.e. ≥75 years), (ii) active cancer, and (iii) surgery in the prior 4 weeks. Results We studied 1244 patients, of whom 586 (47.1%) were women. The median age was 61 (Q1-Q3; 50-71) years. There were 202 (16.3% of total available) patients aged 75 years or older, 101 (10%) with active cancer, and 108 (14.8%) with prior surgery. A total of 946 (89.3%) patients had intermediate-risk PE, and 113 (10.7%) were classified in the high-risk group. Patients aged ≥75 years more frequently suffered haemodynamic decompensation (7.5% vs 1.6% aged &amp;lt;75 years; p&amp;lt; 0.001), major bleeding (12.7% vs 4.5%; p&amp;lt;0.001), and death (9.2% vs 2.2%; p&amp;lt;0.001); Table 1. In a multivariable logistic regression model, age remained associated with death, major bleeding, and haemodynamic decompensation after adjustment for a key prognostic factor (high-risk PE). The same, except for decompensation, was observed after conditioning for sex, high-risk PE, and cancer status. Patients with active cancer showed a tendency to a higher 30-day case fatality when compared with patients with no active cancer, without reaching statistical significance; Table 1. Recent surgery did not appear to influence the outcome rate in this cohort. No differences were found among the three subgroups regarding the reduction of the mPAP following CDT ; Table 2. Conclusions Our results point to age as a strong predictor of early mortality and decompensation in patients undergoing CDT, even after adjusting for the higher rate of high-risk PE in the elderly. The clinical net benefit of CDT in the elderly when accounting for bleeding and the risk of haemodynamic decompensation remains unclear.Efficacy and safety outcomes of CDTmPAP values before and after CDT

Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: haemodynamic outcome at 3 months

Abstract Background Haemodynamic data months after mechanical thrombectomy for pulmonary embolism (PE) are scarce. Aims To assess the haemodynamic effects of mechanical thrombectomy in acute PE with right heart overload. Methods In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after the first 20 patients completed their three months of follow-up. Results Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients (17%) were at high or intermediate-high (76%) risk and had bilateral pulmonary embolisms (79%). Before thrombectomy, systolic pulmonary arterial pressure (sPAP) was severely elevated (mean 51.3±11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p&amp;lt;0.001) immediately following the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p=0.002) (Figure). Right ventricle (RV)/left ventricle (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p&amp;lt;0.001). The proportion of patients with a TAPSE/sPAP ratio &amp;lt;0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p=0.007). There were no procedure-related major adverse events. Conclusions Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.Systolic pulmonary artery pressure

Catheter-directed therapies impact on intermediate-high- and high-risk pulmonary embolism patients

Abstract Introduction Intermediate-high- and high-risk pulmonary embolism (PE) patients treated with anticoagulation alone are associated with a considerable risk of circulatory collapse, death, or long-term pulmonary hypertension. Pulmonary Embolism Response Teams (PERT) have been created to deliver PE patients a better care. Catheter Directed Therapies (CDT), with mechanical thrombolysis and/or local fibrinolysis allow faster reperfusion and hemodynamic improvement without the systemic hemorrhagic effects of systemic fibrinolysis. The clinical evidence of its benefits is lacking. Objectives This analysis aims to describe the hemodynamics, morphological and perfusion improvement in intermediate-high- and high-risk acute PE patients submitted to CDT. Methods Prospective registry of consecutive intermediate-high- and high-risk PE patients submitted to CDT (mechanical thrombolysis with PenumbraÔ aspiration system and/or intrapulmonary local fibrinolysis with alteplase) in a single tertiary center. A multiparametric follow-up protocol was designed to evaluate echocardiographic, CT-scan, pulmonary angiogram, and right heart catheterization data at admission and at 3 months after CDT. The paired samples t-Test was used for the analysis of the variables. Results 26 PE patients (42.3% male, mean age 59 years old) were submitted to CDT (19% combined Penumbra and local fibrinolysis, 12% isolated Penumbra and 69% isolated local fibrinolysis). Baseline characteristics, laboratorial, imaging and procedure data are summarized in the figure 1. No major bleeding was seen during or after the procedure. 1 pulmonary artery dissection and 1 Penumbra burr partial avulsion occurred, both with conservative treatment with good result. 3 patients died during the follow-up (1 for oncologic disease, 1 for septic shock and 1 after discharge with undetermined cause). Of the remaining, 18 patients completed the 3-month follow-up protocol. At 3 months, a significant improvement was seen in the patients’ hemodynamics with 3.3mmHg mean drop of RA pressure (p 0.007), 16.1mmHg mean drop of systolic PA pressure (p &amp;lt;0.001), 8.0mmHg mean drop of mean PA pressure (p&amp;lt;0.001), 1.4L/min and 0.7L/min/m2 mean increases in cardiac output and index (p 0.003, p 0.001), and a tendency to a 0.8 Wood units decrease in the pulmonary vascular resistance (p 0.093). It was also seen an improvement in the perfusion defects with a mean drop of 7.9 points in the modified Miller index (p &amp;lt;0.001) and an improvement in the RV function with a mean decrease of 0.5 in the RV/LV ratio by CT-scan (p &amp;lt;0.001), a mean increase of 5.6mm in TAPSE (p &amp;lt;0.001) and a decrease of median NT-proBNP levels in 2866pg/ml (p &amp;lt;0.001). Conclusions In patients with intermediate-high- and high-risk PE, the use of CDT with mechanical thrombolysis and/or local fibrinolysis is safe and associated with improvement in hemodynamics, RV function and perfusion defects.Table 1.baseline characteristicsTable 2.results

Abstract 13715: Catheter-Based Therapies in High-Risk Pulmonary Embolism: Outcomes From a Tertiary Referral Center

Introduction: Prompt and effective treatment of pulmonary embolism (PE) is essential to prevent morbidity and mortality. We aim to evaluate and compare the effectiveness of two FDA-approved catheter-based therapies (CBT) for acute high-risk PE: ultrasound-assisted catheter-directed thrombolysis EKOS (EKOS Corporation, Bothell, WA) and Penumbra Indigo aspiration thrombectomy (Penumbra Inc., Alameda, CA, USA). Methods: Patients with acute high-risk submassive or massive PE who underwent CBTs between 09/2014 and 08/2022 at our institution were identified. The primary efficacy outcome was the change in the echocardiographic RV/LV diameter ratio within 48 to 72h of procedure. Results: A total of 189 patients underwent EKOS (n=119) or Penumbra (n=70) for submassive (n=175) and massive (n=14) PE (Table). Both groups had similar demographics and clinical characteristics except for prior DVT. Mean age was 60.6±14.3 years old and 55.6% were male. The RV/LV ratio showed significant improvement post intervention, with 21.2% decrease in the EKOS group (EG) and 35.6% in the Penumbra group (PG). The PG had a greater decrease in RV/LV (median change 0.396 (IQR, 0.347) vs. 0.207 (IQR, 0.306), p&lt;0.001). In the cohort, 25 adverse events were reported (13.2%). The rate of complications did not differ between the 2 groups, with 15.1% in EG and 10% in PG. In terms of bleeding complications, GUSTO moderate bleeding was observed in 8 cases (5 in EG and 3 in PG), while severe bleeding was observed in 3 (2 in EG and 1 in PG), including 1 intracranial hemorrhage in the PG. ICU admissions were higher in the PG (p&lt;0.001), but median hospital and ICU stays were comparable. No significant difference was found in the rate of in-hospital mortality (2.5% in EG, 4.3% in PG, p=0.672). Conclusion: Both CBT options are promising for treating submassive PE, with efficacy outcomes favoring Penumbra thrombectomy. Longer follow-up and randomized controlled trials are needed for definitive conclusions.

Underuse of reperfusion therapy with systemic thrombolysis in high-risk acute pulmonary embolism in a Portuguese center

IntroductionReperfusion therapy is generally recommended in acute high-risk pulmonary embolism (HR-PE), but several population-based studies report that it is underused. Data on epidemiology, management and outcomes of HR-PE in Portugal are scarce. ObjectiveTo determine the reperfusion rate in HR-PE patients, the reasons for non-reperfusion, and how it influences outcomes. MethodsIn this retrospective cohort study of consecutive HR-PE patients admitted to a thromboembolic disease referral center between 2008 and 2018, independent predictors for non-reperfusion were assessed by multivariate logistic regression. PE-related mortality and long-term MACE (cardiovascular mortality, PE recurrence and chronic thromboembolic disease) were calculated according to the Kaplan–Meier method. Differences stratified by reperfusion were assessed using the log-rank test. ResultsOf 1955 acute PE patients, 3.8% presented with hemodynamic instability. The overall reperfusion rate was 50%: 35 patients underwent systemic thrombolysis, one received first-line percutaneous embolectomy and one rescue endovascular treatment. Independent predictors of non-reperfusion were: age, with >75 years representing 12 times the risk of non-treatment (OR 11.9, 95% CI 2.7–52.3, p=0.001); absolute contraindication for thrombolysis (31.1%), with recent major surgery and central nervous system disease as the most common reasons (OR 16.7, 95% CI 3.2–87.0, p<0.001); and being hospitalized (OR 7.7, 95% CI 1.4–42.9, p=0.020). At a mean follow-up of 2.5±3.3 years, the survival rate was 33.8%. Although not reaching statistical significance for hospital mortality, mortality in the reperfusion group was significantly lower at 30 days, 12 months and during follow-up (relative risk reduction of death of 64% at 12 months, p=0.013). Similar results were found for MACE. ConclusionsIn this population, the recommended reperfusion therapy was performed in only 50% of patients, with advanced age and absolute contraindications to fibrinolysis being the main predictors of non-reperfusion. In this study, thrombolysis underuse was associated with a significant increase in short- and long-term mortality and events.

Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: hemodynamic outcomes at three months

BackgroundMechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload.MethodsIn this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up.ResultsTwenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events.ConclusionsMechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.

Successful Management of High-Risk Acute Pulmonary Embolism in Patients with Undetected Hepatocellular Carcinoma: A Case Report

Background: Acute pulmonary embolism (PE) as the first sign of hepatocellular carcinoma (HCC) is rare. It is a deadly disease with high morbidity and mortality. Despite the high prevalence of PE, the diagnosis is still challenging, mainly due to the unpredictability of symptoms. The stratification of acute pulmonary embolism is important because it determines the right steps in decision-making. Case Illustration: A 45-year-old man went to a private hospital's emergency room (ER) with sudden shortness of breath. He was desaturated and shocked. He was assessed as having an acute coronary syndrome (ACS), got loaded with dual antiplatelets, and was referred to our hospital. We rule out ACS because the patient's complaint is sudden shortness of breath and desaturation. Acute PE was diagnosed after bedside transthoracal echocardiography (TTE) in the ER revealed right ventricular (RV) dysfunction. We continued with the computed tomography pulmonary artery (CTPA) examination and found a thrombus in the pulmonary artery. We assessed patients with high-risk PE and performed thrombolysis. Initially, we suspected unprovoked PE because we did not find a clear trigger, such as malignancy, prolonged bedriddenness, recent surgery, or old age. We accidentally found HCC from the patient's CTPA evaluation, and HBsAg was reactive. Conclusion: Every case of dyspnea that shows up at an emergency room should have acute PE taken into consideration in the differential diagnosis. In patients with suspected PE without obvious risk factors, we can use CT to triple-rule out ACS, aortic dissection, and pulmonary embolism. Patients treated with thrombolytic therapy show rapid improvement, which may lead to a lower rate of mortality and morbidity. Keyword: Acute Coronary Syndrome, Acute Pulmonary Embolism, Hepatocellular Carcinoma, Thrombolysis, Unprovoked.

Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up.

High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.

Trends and Outcomes of Interhospital Transfer for High-Risk Acute Pulmonary Embolism: A Nationwide Analysis

BackgroundData on outcomes of patients with high-risk acute pulmonary embolism (PE) transferred from other hospitals are scarce. MethodsWe queried the Nationwide Readmissions Database for admissions who were ≥18 years old, and with a primary discharge diagnosis of acute high-risk PE between the years 2016 and 2019. The main outcome of interest was the difference in all-cause in-hospital mortality between patients admitted directly to small/medium hospitals; patients admitted directly to large hospitals; and patients transferred to large hospitals. ResultsAmong 11,341 weighted hospitalizations with high-risk PE, 631 (5.6%) patients were transferred to large hospitals. There was no significant change in the rates of transfer during the study period. Transferred patients were younger and had a higher prevalence of comorbidities. They were more likely to present with saddle PE and cor pulmonale and were more likely to receive advanced therapies. In-hospital mortality was not different between patients transferred to large hospitals and those admitted directly to large hospitals (adjusted odd ratio [OR] 1.11, 95% confidence interval [CI] 0.81, 1.54) as well as between patients transferred to large hospitals and those admitted directly to small/medium hospitals (aOR 1.28, 95% CI 0.92, 1.76). The rates of major bleeding and cardiac arrest were higher among transferred patients. Admissions for transferred patients were associated with higher cost and longer length of stay. ConclusionTransferred patients with high-risk PE were more likely to receive advanced therapies. There was no difference in-hospital mortality rates compared with patients admitted directly to the large or small/medium hospitals.

Frontal QRS - T angle is associated with severity and prognosis of acute pulmonary embolism.

The pathological effects of acute pulmonary embolism (APE) on the right ventricle are one of the most important determinants of mortality in patients with APE. Frontal QRS-T angle (fQRSTa) predicts ventricular pathology and poor prognosis in many different cardiovascular diseases. In this study, we investigated whether there is a significant relationship between fQRSTa and APE severity. A total of 309 patients were included in this retrospective study. The severity of APE was classified as massive (high risk), submassive (intermediate risk), or nonmassive (low risk). fQRSTa calculated from standard ECGs. fQRSTa was significantly higher in massive APE patients (p<0.001). fQRSTa was also found to be significantly higher in the in-hospital mortality group (p<0.001). fQRSTa was an independent risk factor for the development of massive APE (odds ratio:1.033; 95% CI: 1.012-1.052; p<0.001). Our study showed that increased fQRSTa predicts high-risk APE patients and mortality in APE patients.

Fixed-dose ultrasound-accelerated thrombolysis for acute pulmonary embolism: short- and long-term outcome data from a single-center study

Abstract Funding Acknowledgements Type of funding sources: None. Background Data on clinical outcomes after fixed-dosed ultrasound-accelerated thrombolysis (USAT) for acute pulmonary embolism (PE) is still limited, particularly concerning safety and long-term course. Methods We studied patients with acute PE treated with USAT at a University Hospital between 2018 and 2022. Patients were candidates to USAT if acute PE fulfilled the criteria of high-risk or intermediate-high risk (plus additional markers of clinical severity or early deterioration) as per European guidelines. USAT was given at a standard regimen of 10 mg alteplase/catheter over 15 hours. Early outcomes included: mean pulmonary arterial pressure (mPAP) before and after treatment, National Early Warning Score (NEWS) during USAT; 30-day all-cause death, 30-day hemodynamic decompensation, 30-day PE recurrence, and 30-day major bleeding complications (ISTH definition). Late outcomes were: confirmed CTEPH, persistent post-PE dyspnea, and "post-PE impairment" (PPEI), as defined by the combination of dyspnea with sPAP&amp;gt;35 mm Hg, TAPSE &amp;lt;1.6cm, or RV/RA gradient &amp;gt;36 mmHg, death. Results We included 161 patients: the mean age was 67.8 (SD 14.6) years and 96 were men. All had acute bilateral PE and were treated with two catheters for a median alteplase dose of 20 mg. All patients received anti-Xa activity-adjusted unfractionated heparin, except one, who received argatroban. mPAP decreased from a mean of 35.6 (SD 9.8) to 25.6 (SD 8.2) mmHg after a 15-hour course of treatment (absolute difference 10.2 mmHg; SD 8.1). The NEWS decreased from a median of 5 (Q1-Q3: 4-6) points before USAT to 3 (Q1-Q3: 2-4) points after USAT. No hemodynamic decompensations were recorded within 30 days of hospitalization. One (0.6%) recurrence of PE within 30 days occurred. Two major bleeding (1.2%), of which one (0.6%) was intracranial and fatal, were observed. No other deaths were recorded within 30 days of acute PE. Of 125 patients followed at our center and included in the long-term analysis (median follow-up time 104, Q1-Q3 91-200, days), CTEPH was diagnosed in 2 (1.6%) patients. In one patient, CTEPH was most probably pre-existing, namely present already at the time of "acute" PE, based on hemodynamic and radiological findings. CTEPH was incident in the other patient. 24 (19.2%) patients reported persistent dyspnea, of whom 5 (4.0%) fulfilled the PPEI criteria. Death was recorded in 8 (6.4%) patients after a median of 591 (Q1-Q3; 517-710) days and no event was PE-related. One (0.8%) recurrent PE occurred. Conclusions USAT rapidly reduced the mean pulmonary arterial pressure in selected intermediate-high and high-risk acute PE with a good safety profile. Only 4.0% patients had residual symptoms and right ventricular dysfunction over long-term follow-up. This data reassures USAT being an effective and safe option for acute PE also in terms of long-term outcomes.