Management Of Acute Pulmonary Embolism Research Articles

Racial and gender disparities in the management of acute pulmonary embolism: Presented at the American College of Cardiology Annual Scientific Session & Expo, March 4-6, 2023, New Orleans, Louisiana.

Racial and gender disparities in the management of acute pulmonary embolism: Presented at the American College of Cardiology Annual Scientific Session & Expo, March 4-6, 2023, New Orleans, Louisiana.

Reduced mortality associated with pulmonary embolism response team consultation for intermediate and high-risk pulmonary embolism: a retrospective cohort study

BackgroundThe management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation.MethodsAt a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation.ResultsSix hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS.(-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011).These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras.ConclusionsWe observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.

Anticoagulation in the Management of Acute Pulmonary Embolism—A Review

AbstractVenous thromboembolism (VTE) is a very frequent cardiovascular entity that encompasses deep vein thrombosis and pulmonary embolism (PE). This last entity represents a major cause of cardiovascular morbidity and mortality. The incidence of PE and the rate of PE-related morbidity significantly increase with age, race, and underlying medical conditions, such as malignancy. Given the recent advances in diagnostic strategies and algorithms, patients can be risk assessed and treated promptly to avoid disease progression. Anticoagulation is the mainstay of treatment for acute PE that is not hemodynamically unstable. Direct oral anticoagulants, such as apixaban, rivaroxaban, or edoxaban, are currently the preferred agents for the treatment of patients who present with acute PE or for long-term treatment. Treatment duration should be continued for at least 3 months, and all patients should be assessed for extended duration of therapy based on the precipitating factors that led to the development of the VTE. Novel anticoagulant agents targeting factor XI/XIa are currently being investigated in phases 2 and 3 clinical trials, representing an attractive option in anticoagulation therapies in patients with VTE. For hemodynamically unstable patients, systemic thrombolysis is the treatment of choice, and it may also be of benefit—in reduced dose—for patients with intermediate to high risk who are at risk of hemodynamic collapse.

The Role of IVC Filters in the Management of Acute Pulmonary Embolism.

Venous thromboembolism (VTE), comprising deep venous thrombosis (DVT) and pulmonary embolism (PE), is a prevalent cardiovascular condition, ranking third globally after myocardial infarction and stroke. The risk of VTE rises with age, posing a growing concern in aging populations. Acute PE, with its high morbidity and mortality, emphasizes the need for early diagnosis and intervention. This review explores prognostic factors for acute PE, categorizing it into low-risk, intermediate-risk, and high-risk based on hemodynamic stability and right ventricular strain. Timely classification is crucial for triage and treatment decisions. In the contemporary landscape, low-risk PE patients are often treated with Direct Oral Anticoagulants (DOACS) and rapidly discharged for outpatient follow-up. Intermediate- and high-risk patients may require advanced therapies, such as systemic thrombolysis, catheter-directed thrombolysis, mechanical thrombectomy, and IVC filter placement. The latter, particularly IVC filters, has witnessed increased usage, with evolving types like retrievable and convertible filters. However, concerns arise regarding complications and the need for timely retrieval. This review delves into the role of IVC filters in acute PE management, addressing their indications, types, complications, and retrieval considerations. The ongoing debate surrounding IVC filter use, especially in patients with less conventional indications, reflects the need for further research and data. Despite complications, recent studies suggest that clinically significant issues are rare, sparking discussions on the appropriate and safe utilization of IVC filters in select PE cases. The review concludes by highlighting current trends, gaps in knowledge, and potential avenues for advancing the role of IVC filters in future acute PE management.

Evaluation of Four Validated Risk Scores to Predict Outcomes in Hispanic Patients With Acute Pulmonary Embolism.

Risk stratification plays an essential role in the management of acute pulmonary embolism (PE). Several risk scores have been studied to support risk stratification and management. While ethnic differences in acute PE risk factors exist, current risk scores lack validation for Hispanic patients. Therefore, the present study retrospectively investigated the performance of the pulmonary embolism severity index (PESI), simplified PESI (sPESI), the European Society of Cardiology risk assessment (ESC), and the Bova score, to predict 30-day mortality in Hispanic patients presenting with an acute PE. Among 437 patients admitted with acute PE, 30-day mortality was 10.8%; 30-day mortality in low-risk groups ranged from 0% (sPESI, ESC) to 0.2% (PESI, Bova), and 3.0% (Bova) to 5.7% (PESI) in the highest risk groups, respectively. All four scores produced statistically significant discrimination between different risk strata. However, no single scoring system was able to identify all patients with 30-day mortality. The findings of the present study suggest that PESI, sPESI, ESC, and Bova scores provide important information about 30-day mortality in Hispanic in-patients presenting with acute PE. However, additional clinical information could further improve predictability that is not provided by a single scoring system.

Racial and gender disparities in the management of acute pulmonary embolism

ObjectiveThe aim of this study was to assess race and sex disparities in use and outcomes of various interventions in patient with acute pulmonary embolism (PE). MethodsWe included 129,445 patients with acute PE from the NIS from January 2016 to December 2019. Rates of inferior vena cava (IVC) filter placement, catheter-directed thrombolysis (CDT), CDT with ultrasound, systemic thrombolysis, surgical embolectomy, percutaneous thrombectomy, extracorporeal membrane oxygenation, and mechanical ventilation were compared between race and sex subgroups, along with length of hospital stay, major bleeding events, mortality, and other adverse events. Multivariate linear regression analysis was used to adjust for variables that were significantly different between race and sex, including demographic factors, comorbidities, socioeconomic factors, and hospital characteristics. ResultsCompared with White male patients, all subgroups had significantly higher odds of in-hospital mortality highest in Hispanic male patients (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.090-1.640; P < .01). All subgroups also had a higher odds of major bleeding events and increased length of stay. All subgroups also had lower odds of receiving CDT, lowest in Black female patients (OR, 0.740; 95% CI, 0.660-0.820; P < .001) and Hispanic female patients (0.780; 95% CI, 0.650-0.940; P < .001) compared with White male patients. There was no significant difference in the use of systemic thrombolysis among subgroups. ConclusionsBlack and Hispanic patients and female patients are less likely to undergo CDT compared with White male patients, in addition to having higher odds of mortality, major bleeding, and increased length of stay after management of PE. Further efforts are needed to mitigate disparate outcomes of PE management at not only an institutional, but at a national, level to promote health care equality.

Mechanical Support Strategies for High-Risk Procedures in the Invasive Cardiac Catheterization Laboratory: A State-of-the-Art Review.

Thanks to advancements in percutaneous cardiac interventions, an expanding patient population now qualifies for treatment through percutaneous endovascular procedures. High-risk interventions far exceed coronary interventions and include transcatheter aortic valve replacement, endovascular management of acute pulmonary embolism and ventricular tachycardia ablation. Given the frequent impairment of ventricular function in these patients, frequently deteriorating during percutaneous interventions, it is hypothesized that mechanical ventricular support may improve periprocedural survival and subsequently patient outcome. In this narrative review, we aimed to provide the relevant evidence found for the clinical use of percutaneous mechanical circulatory support (pMCS). We searched the Pubmed database for articles related to pMCS and to pMCS and invasive cath lab procedures. The articles and their references were evaluated for relevance. We provide an overview of the clinically relevant evidence for intra-aortic balloon pump, Impella, TandemHeart and ECMO and their role as pMCS in high-risk percutaneous coronary intervention, transcatheter valvular procedures, ablations and high-risk pulmonary embolism. We found that the right choice of periprocedural pMCS could provide a solution for the hemodynamic challenges during these procedures. However, to enhance the understanding of the safety and effectiveness of pMCS devices in an often high-risk population, more randomized research is needed.

Development and validation of a clinical prediction model for the diagnostic management of acute pulmonary embolism: an individual participant data meta-analysis

Abstract Background/Introduction Risk stratification is used for decisions about imaging in patients with clinically suspected acute pulmonary embolism (PE). Purpose To develop a clinical prediction model that provides an individualized, accurate probability estimate for acute pulmonary embolism (PE) based on readily available clinical items and D-dimer concentrations. Methods An individual participant data meta-analysis was performed based on sixteen studies with data from 28,305 adult patients with clinically suspected PE from various clinical settings. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict PE at baseline or during follow-up of 30-90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value &amp;lt; 0.10. Discrimination (c-statistic with 95% CI and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was compared to algorithms based on the Wells score and D-dimer testing. Results The final model included age (in years), sex, previous VTE, recent surgery/immobilization, hemoptysis, cancer, clinical signs of DVT, inpatient status, D-dimer (in μg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95%-CI, 0.85-0.89; 95%-PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). In the lower range of probabilities, the model slightly overestimated VTE probability. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c- statistic 0.73; 95%-CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95%-CI, 0.76- 0.81). Conclusion(s) The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study.Calibration plot of the new model

Optimizing and Extending the Risk-Adapted Management of Acute Pulmonary Embolism beyond the Acute Phase: Progress in Pulmonary Embolism Research.

Optimizing and Extending the Risk-Adapted Management of Acute Pulmonary Embolism beyond the Acute Phase: Progress in Pulmonary Embolism Research.

State of the Art Management of Acute Pulmonary Embolism

The desire for surgical intervention for pulmonary embolism (PE) precipitated the development of cardiopulmonary bypass, and therefore a new era in history of cardiac surgery, cardiology, and medicine. However, the advent of systemic thrombolysis and catheter-directed therapy have decreased interest in surgical management of PE. Surgical pulmonary embolectomy is limited to patients in critical condition with high mortality after other interventions have failed. The issue with clinicians delaying surgical pulmonary embolectomy is that in the interim patients may become critically ill with irreversible end organ dysfunction. Management necessitates decompression of RV afterload by relieving PE obstruction to improve RV function and left ventricular filling. Understanding the pathophysiology of right ventricular outflow tract (RVOT) obstruction and RV failure with a multidisciplinary heart team is paramount.

OC 11.1 Development and Validation of a Clinical Prediction Model for the Diagnostic Management of Acute Pulmonary Embolism: An Individual Participant Data Meta-Analysis

OC 11.1 Development and Validation of a Clinical Prediction Model for the Diagnostic Management of Acute Pulmonary Embolism: An Individual Participant Data Meta-Analysis

When should we involve interventional radiology in the management of acute pulmonary embolism?

Pulmonary embolism (PE) is a common disease associated with high morbidity and mortality. Currently, guidelines recommend systemic thrombolysis in patients with haemodynamic instability (high-risk PE) or patients with intermediate-high-risk PE with haemodynamic deterioration. Nevertheless, more than half of high-risk PE patients do not receive systemic thrombolysis due to a perceived increased risk of bleeding. In these cases, percutaneous catheter-directed therapy (CDT) or surgical embolectomy should be considered. CDT has emerged and appears to be an effective alternative in treating PE, with a hypothetical lower risk of bleeding than systemic thrombolysis, acting directly in the thrombus with a much lower dose of thrombolytic drug or even without thrombolytic therapy. CDT techniques include catheter-directed clot aspiration or fragmentation, mechanical embolectomy, local thrombolysis, and combined pharmaco-mechanical approaches. A few observational prospective studies have demonstrated that CDT improves right ventricular function with a low rate of haemorrhage. Nevertheless, the evidence from randomised controlled trials is scarce. Here we review different scenarios where CDT may be useful and trials ongoing in this field. These results may change the upcoming guidelines for management and treatment of PE, establishing CDT as a recommended treatment in patients with acute intermediate-high-risk PE.

Combined aspartate aminotransferase level and PE-SARD score predict 1-month bleeding risk in acute pulmonary embolism

BackgroundAnti-coagulation is the cornerstone management of acute pulmonary embolism (PE), which is a double-edged sword, as it increases the risk of bleeding. Thus, predicting bleeding risk is necessary. The liver produces most coagulation factors to maintain the coagulation balance. However, the association between liver dysfunction markers and bleeding risk has not been thoroughly investigated. MethodsA single-center, retrospective analysis of patients with acute PE was performed. First, the authors studied the association between liver dysfunction indexes and the 1-month bleeding risk. Then, they investigated whether it is more effective to predict the bleeding risk using a new joint model, i.e., adding liver dysfunction indexes to the PE-SARD score, which is the first score to assess the bleeding risk of acute PE. ResultsAmong 469 patients with acute PE, 34 patients (7.2%) had bleeding events within 1 month after the onset. The levels of aspartate aminotransferase (AST) were higher in the bleeding group compared with the non-bleeding group (36.0 [18.25–90.0] vs. 23.0 [18.0–31.0], p = 0.008). Compared with AST<40, the odds ratios of 80≤AST<120 and AST≥120 were significant (8.825 [2.449–31.804] and 8.023 [2.543–25.315] respectively, p<0.01), even when adjusted for nine confounding factors (p<0.05). The area under the curve of PE-SARD combined with AST was significantly higher than that of the PE-SARD score (p = 0.02). ConclusionsIn PE patients, AST is an independent factor in predicting the 1-month bleeding risk, and a novel joint model that combines AST and PE-SARD score improved the predictive efficiency for the 1-month bleeding risk.

Diagnostic management of acute pulmonary embolism: a prediction model based on a patient data meta-analysis.

Risk stratification is used for decisions regarding need for imaging in patients with clinically suspected acute pulmonary embolism (PE). The aim was to develop a clinical prediction model that provides an individualized, accurate probability estimate for the presence of acute PE in patients with suspected disease based on readily available clinical items and D-dimer concentrations. An individual patient data meta-analysis was performed based on sixteen cross-sectional or prospective studies with data from 28 305 adult patients with clinically suspected PE from various clinical settings, including primary care, emergency care, hospitalized and nursing home patients. A multilevel logistic regression model was built and validated including ten a priori defined objective candidate predictors to predict objectively confirmed PE at baseline or venous thromboembolism (VTE) during follow-up of 30 to 90 days. Multiple imputation was used for missing data. Backward elimination was performed with a P-value <0.10. Discrimination (c-statistic with 95% confidence intervals [CI] and prediction intervals [PI]) and calibration (outcome:expected [O:E] ratio and calibration plot) were evaluated based on internal-external cross-validation. The accuracy of the model was subsequently compared with algorithms based on the Wells score and D-dimer testing. The final model included age (in years), sex, previous VTE, recent surgery or immobilization, haemoptysis, cancer, clinical signs of deep vein thrombosis, inpatient status, D-dimer (in µg/L), and an interaction term between age and D-dimer. The pooled c-statistic was 0.87 (95% CI, 0.85-0.89; 95% PI, 0.77-0.93) and overall calibration was very good (pooled O:E ratio, 0.99; 95% CI, 0.87-1.14; 95% PI, 0.55-1.79). The model slightly overestimated VTE probability in the lower range of estimated probabilities. Discrimination of the current model in the validation data sets was better than that of the Wells score combined with a D-dimer threshold based on age (c-statistic 0.73; 95% CI, 0.70-0.75) or structured clinical pretest probability (c-statistic 0.79; 95% CI, 0.76-0.81). The present model provides an absolute, individualized probability of PE presence in a broad population of patients with suspected PE, with very good discrimination and calibration. Its clinical utility needs to be evaluated in a prospective management or impact study. PROSPERO ID 89366.

Risk stratification of pulmonary embolism.

Pulmonary embolism is the third most frequent type of cardiovascular disease behind coronary artery disease and stroke. Patients with acute pulmonary embolism have significant variability in short-term mortality from less than 0.6% in low-risk patients to 19% in high-risk patients. Risk stratification plays an important role in the management of acute pulmonary embolism as it can determine the need for urgent reperfusion therapies versus conservative strategies. The three fundamental steps of risk stratification include the immediate identification of patients that are at high risk for mortality, the identification of patients that are at an increased risk of complications from pulmonary embolism that requires hospital monitoring and potential escalation of therapies, and the identification of patients at a low risk that can be treated as an outpatient. It is vital to immediately identify high-risk patients for mortality so that they can be evaluated for urgent reperfusion therapies to improve outcomes. Risk stratification for intermediate-risk patients is based on right ventricular dysfunction in patients with hemodynamic stability. RV dysfunction can be assessed by clinical signs and symptoms along with ECHO and cardiac biomarkers. Identifying the low-risk population can help reduce the healthcare burden by allowing for early discharge and outpatient management.

Home treatment versus early discharge for the outpatient management of acute pulmonary embolism: A non-interventional, post-hoc cohort analysis

IntroductionWe prospectively investigated whether home treatment of pulmonary embolism (PE), is as effective and safe as the recommended early discharge management in terms of outcomes at 3 months. MethodsWe performed a post hoc analysis of prospectively and consecutively recorded data in acute PE patients from a tertiary care facility between January 2012 and November 2021. Home treatment was defined as discharge to home directly from the emergency department (ED) after <24 h stay. Early discharge was defined as in-hospital stay of ≥24 h and ≤48 h. Primary efficacy and safety outcomes were a composite of PE-related death or recurrent venous thrombo-embolism, and major bleeding, respectively. Outcomes between groups were compared using penalized multivariable models. ResultsIn total, 181 patients (30.6 %) were included in the home treatment group and 463 (69.4 %) patients in the early discharge group. Median duration of ED stay was 8.1 h (IQR, 3.6–10.2 h) in the home treatment group, and median length of hospital stay was 36.4 h (IQR, 28.7–40.2) in the early discharge group. The adjusted rate of the primary efficacy outcome was 1.90 % (95 % CI, 0.16–15.2) vs 2.05 % (95 % CI, 0.24–10.1) for home treatment vs early discharge (hazard ratio (HR) 0.86 (95 % CI, 0.27–2.74). The adjusted rates of the primary safety outcome did not differ between groups at 3 months. ConclusionsIn a non-randomized cohort of selected acute PE patients, home treatment provided comparable rates of adverse VTE and bleeding events to the recommended early discharge management, and appears to have similar clinical outcomes at 3 months.

Multidisciplinary Pulmonary Embolism Response Team (PERT) a propensity score matched single centre experience from Germany

Abstract Funding Acknowledgements Type of funding sources: None. Background Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). Purpose To investigate the composition and added clinical value of PERT in our city. Methods Over a 5-year period (01/2017-09/2022), patients with confirmed PE were enrolled in a prospective single-centre cohort study (PERT). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE prior and after the formation of PERT at our institution. The primary outcome was in-hospital PE-related mortality before and after the formation of PERT. Results During the period from 2017 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a mean age of 68 years; among these 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 84.9% of the patients. In total, 42.0% were classified as intermediate-risk PE and 11.6% as high-risk PE. First PERT contact originated mostly by emergency departments (33.3 %) and intensive care unit (30.0%), followed by chest pain unit (21.3%) and regular ward (12.0%) (Figure 1a). The participation rate of specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT activations followed by radiologist (95.9%) or anesthesiologist (87.8%). Further disciplines were present in few cases as summarized in Figure 1b. When comparing patients characteristics of the pre-PERT era with the PERT era, more patients were classified as sPESI ≥1 and as high-risk according to ESC 2019 guidelines in the pre-PERT era (78.4% and 18.2%) opposed to the PERT era (71.6 and 11.4%) (Figure 2). A considerable higher all-cause mortality (31.8% vs. 14.8%) and PE-related mortality rate (22.7% vs. 13.6%) was observed in patients in the pre-PERT era compared to the PERT era. After propensity matching (1:1) by including parameters as age, sex, sPESI and ESC risk classes, an univariate regression analyses demonstrated, that the PE management based on a PERT-decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p=0.009) and PE-related mortality (OR, 0.54 [95%CI 0.24-1.18]; p=0.121) compared to patients without a PERT-decision. Conclusion PERT implementation tended to reduce the mortality rate in patients with acute PE. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Long-Term Outcomes of Patients With Pulmonary Embolism Managed With Endovascular Therapies Compared to Medical Therapy

BackgroundGuidelines on the management of acute pulmonary embolism (PE) recommend consideration of endovascular therapies (EVT) for patients at intermediate-high risk. However, long-term data on the outcomes of patients after EVT as compared to medical therapy is lacking. This study aimed to compare outcomes of patients receiving EVT as compared to medical therapy alone at 3 to 6 months.MethodsIn this single-center, retrospective cohort study, 190 patients with PE underwent evaluation for presence of right ventricular (RV) dysfunction by transthoracic echocardiogram, residual perfusion defects on ventilation-perfusion scanning, and functional capacity by 6-minute walk distance (6MWD) at 3 to 6 month follow-up.ResultsFifty-eight (31%) patients received EVT for the management of their acute PE. At follow-up (median 120 [97-170] days), 71% of patients who received EVT had normalization of RV function compared with only 34% of patients who received medical therapy alone (P < .001). Patients who received EVT had a significantly greater increase in their estimated glomerular filtration rate (P = .001), decrease in N-terminal proB-type natriuretic peptide (P = .003), and decrease in hemoglobin values (P = .018). Patients with intermediate-high to high risk PE who received EVT had significantly greater distance achieved on their 6MWD as compared to those who received medical therapy alone (P = .025).ConclusionsPatients with acute PE who received EVT plus medical therapy were more likely to achieve normalization of RV dysfunction at 3 to 6 month follow-up compared to patients who received medical therapy alone. These data suggest that EVT is an effective therapy option for acute PE in intermediate-high and high risk patients with potential durable long-term benefits.

Management of acute pulmonary embolism with sequential hybrid therapy of surgical thrombectomy and rivaroxaban intensive therapy: a case report

Acute pulmonary embolism (PE) is often associated with rapid hemodynamic deterioration or death. Therefore, early therapeutic intervention is important. A 45-year-old man was diagnosed with intermediate-high risk PE, and sequential hybrid therapy consisting of surgical thrombectomy and rivaroxaban intensive therapy was administered. During the course of treatment, echocardiography revealed improvement in pulmonary artery systolic pressure, and thrombus volume analysis by computed tomography revealed a drastic reduction in the size of the thrombus. Sequential hybrid therapy for acute PE not only stabilizes hemodynamics, but may also prevent conversion to chronic thromboembolic pulmonary hypertension by sufficiently reducing the volume of the thrombus.

Clinical controversies in the management of acute pulmonary embolism: evaluation of four important but controversial aspects of acute pulmonary embolism management that are still subject of debate and research

ABSTRACT Introduction Acute pulmonary embolism (PE) is a disease with a broad spectrum of clinical presentations. While some patients can be treated at home or may even be left untreated, other patients require an aggressive approach with reperfusion treatment. Areas covered (1) Advanced reperfusion treatment in hemodynamically stable acute PE patients considered to be at high risk of decompensation and death, (2) the treatment of subsegmental pulmonary embolism, (3) outpatient treatment for hemodynamically stable PE patients with signs of right ventricle (RV) dysfunction, and (4) the optimal approach to identify and treatpost-PE syndrome. Expert opinion Outside clinical trials, hemodynamically stable acute PE patients should not be treated with primary reperfusion therapy. Thrombolysis and/or catheter-directed therapy are only to be considered as rescue treatment. Subsegmental PE can be left untreated in selected low-risk patients, after proximal deep vein thrombosis has been ruled out. Patients with an sPESI or Hestia score of 0 criteria can be treated at home, independent of the presence of RV overload. Finally, health-care providers should be aware of post-PE syndrome and diagnose chronic thromboembolic pulmonary disease (CTEPD) as early as possible. Persistently symptomatic patients without CTEPD benefit from exercise training and cardiopulmonary rehabilitation.