Massive PE Research Articles

(1207) - Combined Inari Thrombectomy and PFO Closure in a Young Patient with Massive PE and Multiple Embolic Events

(1207) - Combined Inari Thrombectomy and PFO Closure in a Young Patient with Massive PE and Multiple Embolic Events

The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis

IntroductionPulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. MethodThis study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. ResultsOf the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. ConclusionEarly identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.

Development and validation of a radiomics nomogram for diagnosis of malignant pleural effusion

ObjectiveWe aimed to develop a radiomics nomogram based on computed tomography (CT) scan features and high-throughput radiomics features for diagnosis of malignant pleural effusion (MPE).MethodsIn this study, 507 eligible patients with PE (207 malignant and 300 benign) were collected retrospectively. Patients were divided into training (n = 355) and validation cohorts (n = 152). Radiomics features were extracted from initial unenhanced CT images. CT scan features of PE were also collected. We used the variance threshold algorithm and least absolute shrinkage and selection operator (LASSO) to select optimal features to build a radiomics model for predicting the nature of PE. Univariate and multivariable logistic regression analyzes were used to identify significant independent factors associated with MPE, which were then included in the radiomics nomogram.ResultsA total of four CT features were retained as significant independent factors, including massive PE, obstructive atelectasis or pneumonia, pleural thickening > 10 mm, and pulmonary nodules and/or masses. The radiomics nomogram constructed from 13 radiomics parameters and four CT features showed good predictive efficacy in training cohort [area under the curve (AUC) = 0.926, 95% CI 0.894, 0.951] and validation cohort (AUC = 0.916, 95% CI 0.860, 0.955). The calibration curve and decision curve analysis showed that the nomogram helped differentiate MPE from benign pleural effusion (BPE) in clinical practice.ConclusionThis study presents a nomogram model incorporating CT scan features and radiomics features to help physicians differentiate MPE from BPE.

Thrombolysis for Massive PE: Is Less More?

Thrombolysis for Massive PE: Is Less More?

Abstract 18131: Outcomes of Catheter-Based Thrombectomy versus Surgical Embolectomy Among Patients With Massive Pulmonary Embolism: A Nationwide Analysis From the United States

Background: Clinical outcomes of catheter-based thrombectomy (CBT) compared with surgical embolectomy (SE) in patients with massive pulmonary embolism (mPE) have not been previously examined. Methods: We conducted a retrospective cohort study using the 2016-2020 National Inpatient Sample database to compare the outcomes of CBT versus SE in patients with mPE. Outcomes of interest included risk-adjusted in-hospital mortality, major bleeding, stroke, acute kidney injury (AKI), hospital length of stay (LOS), and total cost. Results: The total cohort included 5,845 patients with mPE, of which 5,490 (93.9%) underwent CBT and 215 (3.7%) underwent SE. After risk-adjustment, CBT had similar odds of in-hospital mortality (adjusted odds ratio [aOR] 1.49, 95% confidence interval [CI] 0.60-3.66, p=0.37) and stroke (aOR 1.49, 95% CI 0.30-7.38, p=0.62), lower odds of major bleeding (aOR 0.28, 95% CI 0.13-0.63, p<0.01), and higher odds of AKI (aOR 2.40, 95% CI 1.11-5.17, p=0.02) compared with SE. CBT had a similar LOS (p=0.58) and total cost (p=0.23) compared with SE. Between 2016 and 2020, there was a temporal increase in the performance of CBT in patients with mPE (p trend <0.01). Conclusions: In patients with massive PE, CBT was associated with similar in-hospital mortality, stroke, LOS, and total cost, lower major bleeding, and higher AKI compared with SE. Randomized controlled trials are indicated to confirm our findings.

Predictors of Mortality in Pulmonary Embolism: A Real-Life Study

Objective: The primary aim of this study was to investigate the mortality and associated factors in patients with pulmonary embolism. Methods: A retrospective analysis was performed on adult patients with pulmonary embolism who applied to X University Hospital between January 1, 2017, and January 1, 2023. All-cause mortality and related factors in pulmonary embolism patients were determined. Results: This study included 152 patients with a median age of 59 years and 81 (53.3%) women. The all-cause mortality rate was 25.7%, and pulmonary embolism-related deaths were 1.3%. Age (p<0.001), chronic obstructive pulmonary disease (COPD) (p=0.013), heart failure (p=0.018), atrial fibrillation (p=0.015), massive pulmonary embolism (p=0.029), hemoglobin level (p<0.001) and NT-Pro BNP level (p<0.001) were significantly associated with increased all-cause mortality. In binary logistic regression analysis, for each unit of increasing pulmonary embolism severity index (PESI) score, mortality increased 2.2-fold (95% CI:1.03-5.09), massive PTE 1.6-fold (95% CI:0.14-17.86), anticoagulant duration (daily) 0.98-fold (95% CI:0.98-0.99) and Hb level (per unit Hb reduction) 0.67-fold (95% CI:0.45-1.02) mortality was increasing. There was no statistical difference between the number of hospitalization days for patients with low and high PESI and simplified PE severity index (sPESI) scores. Conclusions: All-cause mortality in patients with pulmonary embolism increased with age, cardiac diseases, and COPD comorbidities. The PESI and sPESI scores used in the acute phase of PTE were found to be highly reliable in predicting all-cause mortality in PE patients. The diagnosis of massive PE and elevated NT-proBNP levels, a marker of right ventricular dysfunction, were factors that increased mortality.

Prediction of the degree of the right heart chambers overload in patients with acute massive pulmonary embolism based on the results of MSCT diagnostics

The study group included 147 patients at the stage of preparation for emergency surgical treatment of acute massive PE in the period from March 2012 to December 2019 inclusive. As CT indicators of overload of the right chambers of the heart, the usual CT indicators that do not require the use of expert – class computed tomographs were taken – they were the superior vena cava, inferior vena cava, unpaired vein; reflux of the contrast drug into the inferior vena cava; reflux of the contrast drug into the hepatic veins. In the course of the study, a comparative analysis of the average pressure in the pulmonary artery with the above CT indicators was performed. The most stable statistical relationship with the indicators of mean pressure in the pulmonary artery was demonstrated by CT parameters – the diameter of the unpaired vein and the reflux of the contrast agent into the hepatic veins. Based on the results of the work, a method for calculating the actual values of the average pressure in the pulmonary artery based on the CT parameter of the diameter of the unpaired vein is proposed.

Pulmonary embolism response team for hospitalized patients with submassive and massive pulmonary embolism: A single-center experience

BackgroundPulmonary embolism (PE) is a major cause of mortality with presentation varying between few or no symptoms to sudden death. This makes timely and appropriate treatment extremely important. Multidisciplinary PE response teams (PERT) have emerged to improve the management of acute PE. This study aims to describe the experience of a large multihospital single-network institution with PERT. MethodsA retrospective cohort study of patients admitted for submassive and massive PE between 2012 and 2019 was conducted. The cohort was divided based on time of diagnosis and hospital into two groups: non-PERT included patients treated at hospitals that did not initiate PERT and patients diagnosed before the introduction of PERT (June 1, 2014); and the PERT group included those admitted after June 1, 2014, to a hospital with PERT. Patients with low-risk PE and those who had admissions in both time periods were excluded. Primary outcomes included all-cause mortality at 30, 60, and 90 days. Secondary outcomes included causes of death, intensive care unit (ICU) admission, ICU length of stay (LOS), total hospital LOS, type of treatment, and specialty consultations. ResultsWe analyzed 5190 patients, with 819 (15.8%) being in the PERT group. Patients in the PERT group were more likely to receive extensive workup that included troponin-I (66.3% vs 42.3%; P < .001) and brain natriuretic peptide (50.4% vs 20.3%; P < .001). They also more often received catheter-directed interventions (12% vs 6.2%; P < .001) rather than anticoagulation monotherapy. Mortality outcomes were similar between both groups at all measured timepoints. Rates of ICU admission (65.2% vs 29.7%; P < .001), ICU LOS (median, 64.7 hours; interquartile range [IQR], 41.9-89.1 hours vs median, 38 hours; IQR, 22-66.4 hours; P < .001), and total hospital LOS (median, 5 days; IQR, 3-8 days vs median, 4 days; IQR, 2-6 days; P < .001) were all higher among the PERT group. Patients in the PERT group were more likely to receive vascular surgery consultation (5.3% vs 0.8%; P < .001) and the consultation occurred earlier in the admission when compared with the non-PERT group (median, 0 days; IQR, 0-1 days vs median, 1 day; IQR, 0-1; P = .04). ConclusionsThe data presented here showed that there was no difference in mortality after PERT implementation. These results suggest that the presence of PERT increases the number of patients receiving a full PE workup with cardiac biomarkers. PERT also leads to more specialty consultations and more advanced therapies such as catheter-directed interventions. Further research is needed to assess the effect of PERT on long-term survival of patients with massive and submassive PE.

Abstract No. 70 Safety and Clinical Outcomes of Aspiration Thrombectomy in Patients with Massive PE: A Single-Center Retrospective Review

Abstract No. 70 Safety and Clinical Outcomes of Aspiration Thrombectomy in Patients with Massive PE: A Single-Center Retrospective Review

Improved long-term outcomes with catheter-directed therapies over medical management in patients with submassive pulmonary embolism—a retrospective matched cohort study

BackgroundThe benefit of catheter-directed therapy (CDT) for submassive pulmonary embolism (sPE) has been the subject of debate. We sought to determine the short- and long-term mortality and outcomes of CDT compared with anticoagulation for patients with sPE. MethodsWe performed a single healthcare network, multihospital, retrospective cohort study of hospitalizations for sPE from 2012 to 2019. sPE was defined as the presence of right heart strain or elevated biomarkers (troponin I or B-type natriuretic peptide). Patients with massive PE and those who had undergone systemic thrombolysis were excluded. The sPE groups included therapeutic anticoagulation alone or anticoagulation plus CDT (ie, thrombolysis or suction thrombectomy). The primary outcome was mortality at 1, 3, and 5 years. The other measured outcomes included PE-related death, short term mortality (30 days and 3 and 6 months), 30-day treatment-related complications (eg, bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test at 1 year. After 1:1 nearest-neighbor propensity score matching, Kaplan-Meier survival plots were generated, and the treatment groups were compared using log-rank testing. We used Cox multivariate analysis to evaluate the outcomes after clustering at the hospital level, generating matched hazard ratios (mHRs) with associated 95% confidence intervals (CIs). ResultsOf 6746 sPE hospitalizations, the patients who had received CDT were younger (age, 58.9 ± 15.5 years vs 61.5 ± 17.4 years; P = .004), were more frequently White (92.5% vs 85.7%; P < .001), and had presented with a higher mean heart rate (104.6 bpm vs 94.9 bpm; P < .001), lower median systolic blood pressure (129 mm Hg vs 135 mm Hg; P < .001), and a greater incidence of right heart strain (79.2% vs 20.3%; P < .001). A total of 470 patients were matched, with 235 in the CDT group and 235 in the anticoagulation-only group. CDT was associated with a lower risk of mortality compared with anticoagulation at 1 year (7.6% vs 9.8%; mHR, 0.77; 95% CI, 0.65-0.92; P = .004), 3 years (11.1% vs 16.6%; mHR, 0.64; 95% CI, 0.55-0.73; P < .001), and 5 years (14.5% vs 19.1%; mHR, 0.71; 95% CI, 0.66-0.77; P < .001). Anticoagulation alone resulted in a greater incidence of PE-related deaths at 1, 3, and 5 years. The mortality at 30 days and 3 months was similar; however, CDT had resulted in better survival at 6 months (mHR, 0.81; 95% CI, 0.68-0.97; P = .02). No differences were found between the two groups in the incidence of bleeding complications at 30 days, development of chronic thromboembolic pulmonary hypertension, or the mean walking distance at 1 year. ConclusionsCDT plus anticoagulation for sPE was associated with improved long-term survival compared with anticoagulation alone, with a lower incidence of PE-related death and a low complication rate. CDT should be considered for select patients with sPE given its survival benefit.

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL

WHERE ARE YOU GOING: EMERGENCY MANAGEMENT OF A THROMBUS-IN-TRANSIT WITH PERCUTANEOUS MECHANICAL THROMBECTOMY AT A COMMUNITY HOSPITAL

A clinical case of a patient after COVID 19 infection and a thrombus in the right atrium, deep phlebothrombosis, and pulmonary embolism

Background: The coronavirus disease (COVID-19 disease) leads to multiple organ disease, inflammation of the endothelium, and micro- or macrovasculitis that may result in thrombosis of the small vessels, and thrombosis of vessels in various organs, as well as intracardiac thrombosis. Some of the complications may be long-lasting, as in our case, which makes it particularly interesting to discuss. Case report: We present a 73-year-old male patient with a history of permanent atrial fibrillation and chronic heart failure (II NYHA class), popliteal phlebothrombosis, and surgery of the left hip joint. 53 days after a positive rapid test for Covid 19 performed because of fever and coughing, the patient, who is not vaccinated for Covid 19, was hospitalised at our Department with clinical signs of mild respiratory failure and cardiogenic shock.&amp;nbsp; The laboratory tests revealed elevated markers of inflammation. The ECG showed tachyarrhythmia (170/min) and atrial fibrillation. The EchoCG displayed evidence of right systolic dysfunction, pulmonary hypertension, and a massive thrombus in the right atrium. The Doppler ultrasonography revealed the presence of right femoropopliteal thrombosis, while the CT-pulmoangiography showed evidence of massive bilateral PE. A decision was made to perform systemic fibrinolysis, which the patient tolerated without complications. During the hospitalisation, the examinations revealed no evidence of an oncological disease. Conclusion: The reported clinical case confirms the high risk of thrombosis due to a COVID-19 infection, such as phlebothrombosis, atrial thrombosis, and massive bilateral PE, in the absence of optimal anticoagulant therapy and against the backdrop of the administration of antiplatelet therapy roughly 2 months after the onset of the COVID-19 symptoms.

Improved Short- and Long-term Survival with Catheter Directed Therapies over Medical Management in Patients with Submassive Pulmonary Embolism - A Retrospective Matched Cohort Study

The benefit of catheter-directed therapies (CDT) for submassive pulmonary embolism (sPE) is subject of debate. We sought to determine short and long-term mortality and outcomes of CDT compared with anticoagulation (AC) in patients with sPE. This is a single health care network, multi-hospital, retrospective cohort study of all hospitalizations for sPE (2012-2019). sPE was defined as presence of at least one of the following: right heart strain, elevated biomarkers (Troponin-I or B-type natriuretic peptide), or vital sign abnormalities (heart rate ≥110 bpm). Patients with massive PE (systolic blood pressure <90 mmHg or vasopressor support) and those who received systemic thrombolysis were excluded. sPE groups included therapeutic AC alone or AC with CDT (thrombolysis and suction thrombectomy). Measured outcomes included mortality, treatment-related complications (bleeding, transfusion, stroke), chronic thromboembolic pulmonary hypertension, and 6-minute walk test. After 1:1 nearest-neighbor propensity-score matching, Kaplan-Meier survival plots were generated for the treatment groups and compared using log-rank testing (Figure). Multivariate Cox regression was used to determine effect of treatment on 1-year, 3-year, and 5-year survival after adjusting for confounding variables and clustering on hospitals. Of 6746 sPE hospitalizations, 235 patients receiving CDT were matched with 235 patients who received AC. Patients receiving CDT were younger (58.9 ± 15.5 vs 61.5 ± 17.4 years; P = .004) and more likely to be white (92.5% vs 85.7%; P < .001). Those who received CDT presented with higher heart rate, lower systolic blood pressure, and were more likely to have right heart strain (Table). In the matched cohort, no difference was seen in the development of chronic thromboembolic pulmonary hypertension (4.3% vs 4.3%; P = 1.0) at a mean follow-up of 2 years. The 6-minute walk test at 1 year was similar between the 2 groups (332.7 meters vs 318.8 meters; P = .62). However, AC alone was associated with higher PE-related death within 30 days (1.7% vs 0.4%; P = .047). CDT was also associated with lower rate of complications at 30 days (1.49% vs 4.25%; P = .176) and at 3 years (1.49% vs 16.6%; P = .009). CDT was associated with a lower risk of mortality compared with AC at 1 year (7.6% vs 9.8%; hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.65-0.92; P = .004), 3 years (11.1% vs 16.6%; HR, 0.64; 95% CI, 0.55-0.73; P < .001), and 5 years (14.5% vs 19.1%; HR, 0.71; 95% CI, 0.66-0.77; P < .001). CDT for sPE is associated with improved short- and long-term survival compared with AC alone, with a low complication rate. CDT should be considered in select patients with sPE given its survival benefit.TableClinical characteristics for both unadjusted and matched cohorts of patients with sPEUnadjusted cohort, No. (%)Matched cohort, No. (%)AnticoagulationCDTStandardized differenceAnticoagulationCDTStandardized differenceTotal6404 (94.9)343 (5.1)235235Mean age (SD), years61.5 (17.4)58.8 (15.5)0.16859.4 (18.2)59.46 (5.6)0.003Gender Male3087 (48.2)180 (52.5)0.085119 (50.6)125 (53.2)0.051 Female3317 (51.8)163 (47.5)116 (49.4)110 (46.8)Race White5343 (83.4)297 (86.6)0.281205 (87.2)209 (88.9)0.057 Black890 (13.9)24 (7.0)25 (10.6)21 (8.9) Unknown171 (2.7)22 (6.4)5 (2.1)5 (2.1)Ethnicity Hispanic28 (0.4)1 (0.3)0.0631 (0.4)1 (0.4)0.028 Non-Hispanic5333 (83.3)284 (85.5)210 (89.4)208 (88.5) Unknown1041 (16.3)47 (14.2)24 (10.2)26 (11.1)Diabetes1124 (17.6)57 (16.6)0.02556 (23.8)49 (20.9)0.071Hypertension3092 (48.3)155 (45.2)0.062115 (48.9)108 (46.0)0.059History of cancer1757 (27.4)40 (11.7)0.40637 (15.7)33 (14.0)0.048Recent surgery (90 days)1812 (28.3)54 (15.7)0.30649 (20.9)43 (18.3)0.064Anticoagulation655 (10.2)25 (7.3)0.10420 (8.5)18 (7.7)0.031Mean heart rate (SD), bpm94.87 (20.3)104.6 (20.2)0.482104 (19.1)104.2 (19.8)0.013Mean SBP (SD), mmHg136.9 (23.9)132.5 (21.7)0.194129.2 (22.2)132 (22.2)0.126Mean DBP (SD), mmHg79.4 (14.8)82.6 (14.3)0.22381.6 (16.3)81.8 (13.7)0.011RHS on CTA or echo1265 (20.3)271 (79.2)1.458178 (75.7)186 (79.1)0.081CDT, Catheter-directed therapies; CTA, computed tomography angiography; DBP, diastolic blood pressure; RHS, right heart strain; SBP, systolic blood pressure; sPE, submassive pulmonary embolism. Open table in a new tab

P278 WHEN HARRY MET SALLY. DESCRIPTION OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM ARRIVING IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Abstract Premises Pulmonary embolism represents one of the major causes of mortality linked to cardiovascular events. The range of symptoms is extremely wide and its recognition difficult. The patients who therefore come to the emergency room are a diverse population. Purpose to describe the population that refers to the emergency room and finds there a diagnosis of acute pulmonary embolism. Methods Single–center retrospective observational study, on all geriatric patients (&amp;gt; 75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2016 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes, severity scores. Results We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Among those subjected to blood gas analysis 11% showed alteration of pH, 16% showed alteration of pCO2, 8% showed alteration of pO2, 5% of BE, 2% of lactate. 34% showed massive PE, 32% showed organ damage. In particular, 21% showed pulmonary artery dilation, 16% pulmonary infarction and 19% right ventricular dilation. 40% showed elevation of myocardiospecific enzymes. 41% were considered to be at high risk of long–term mortality according to European guidelines, 41% at intermediate risk and 18% at low risk of mortality. 1.4% underwent thrombolysis, 2.4% required intubation. 2.8% needed an operating room for mechanical thrombolysis; 8% of hospitalization in the intensive ward during hospitalization. In–hospital mortality was 7.7%. 5% experienced bleeding during hospitalization following anticoagulation therapy. Conclusions The population that arrives in ED for pulmonary embolism presents extremely varied symptomatological pictures, but an overall high degree of clinical risk and assistance and therapeutic complexity.

P277 SECRET BEYOND THE DOOR. TRIAGE ANALYSIS AND RECOGNITION AT THE DOOR OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM WHO ARRIVE IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM

Abstract Background The range of symptoms of pulmonary embolism is wide and its recognition difficult. Purpose to analyze the efficiency of triage in the EP. Methods Single–center retrospective observational study, on all geriatric patients (&amp;gt;75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes. Results We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Only 4% showed hypotension, 13% tachycardia and 8% desaturation. 39% arrived with their own vehicle. 32% was allocated to the area with low intensity of care, 68% to the area with medium–high intensity of care. As regards the priority code for the visit, 0% received a non–urgency code (white code or code 5), 27.9% a minor urgency code (green code or code 4) and 3.6% a high priority to the visit with assignment to low intensity of care (low intensity yellow or code 3). 63.15% received an emergency code (urgency or code 2) and 5.3% an emergency code (red code or code 1). The severity code at discharge, given on clinical criteria, was a low severity code (white or green) in 18% of cases, while 76% was considered high severity (urgency, yellow code) and in 6% for very high gravity (red code). 34% showed massive PE, 32% showed organ damage. 41% were considered to be at high risk of short–term mortality according to European guidelines, 8% required intensive care and in–hospital mortality was 7.7%. Under triage is 32%. Conclusions The population that arrives in ED due to pulmonary embolism presents extremely varied symptomatological pictures, and an overall high degree of clinical risk and care and therapeutic complexity in spite of the symptoms complained of and vital parameters. Under–riage remains a real problem for ED for this category of patients.

Frequency and prognostic significance of atrial fibrillation in acute pulmonary embolism: A pooled analysis

ObjectiveTo summarize data on the prevalence/incidence, risk factors and prognosis of atrial fibrillation (AF) in patients with acute pulmonary embolism (aPE). MethodsMEDLINE, Embase, and Web of Science were searched to identify all published studies providing relevant data through December 12, 2021. Random-effects meta-analysis method was used to pool estimates. ResultsWe included 27 studies reporting data from a pooled population of 819,380 patients. The prevalence rates were 11.3% for pre-existing AF, 4.7% for newly diagnosed AF, and 13.2% for prevalent (total) AF. Predictors of newly diagnosed AF (from one study) included congestive heart failure (adjusted odds ratio [aOR] 3.33, 95% CI: 1.81–6.12), ischemic heart disease (aOR 3.25, 95% CI: 1.65–6.39), massive PE (aOR 2.67, 95% CI: 1.19–5.99). Overall, AF was associated with increased risk of short-term (aOR 1.54, 95% CI: 1.44–1.64) and long-term mortality (aOR 1.58, 95% CI: 1.26–1.97). In subgroup analyses, all types of AF were associated with increased risk of short-term mortality: pre-existing AF (aOR 1.90, 95% CI: 1.59–2.27), newly diagnosed AF (aOR 1.51, 95% CI: 1.18–1.93), and prevalent AF (aOR 1.50, 95% CI: 1.42–1.60). Pre-existing AF (aOR 2.08, 95% CI: 1.27–3.42) and prevalent AF (aOR 1.29, 95% CI: 1.02–1.63) were also associated with higher long-term mortality. ConclusionAF is present in about one in eight patients with aPE, and is associated with increased short- and long-term mortality. AF might improve risk stratification in patients with aPE.

C-13 | Meta-analysis of Standard vs. Ultrasound-Assisted Thrombolysis in the Management of Acute Pulmonary Embolism

Standard catheter-directed thrombolysis (SCDT) harnesses the therapeutic benefit of systemic thrombolytics by infusing the lytic agent directly into the thrombus, thereby, minimizing the dose and bleeding complications in patients presenting with massive and sub-massive PE. Ultrasound-assisted thrombolysis (USAT) theoretically improves SCDT by disrupting fibrin and increasing the surface area exposed to the agent, but it comes at an increased cost. The purpose of this study is to determine if USAT improves outcomes compared to SCDT.

Use of Venoarterial Extracorporeal Membrane Oxygenation in the Management of Massive Pulmonary Embolism

<h3>Purpose</h3> The management of massive pulmonary embolism with hemodynamic instability remains challenging with high mortality rate, Using Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) is used in general as salvage therapy. Here we report a single center experience. <h3>Methods</h3> Medical records of all patients who underwent VA-ECMO support for massive pulmonary emboli and presented with cardiogenic shock and severe right ventricle dysfunction between January 2015-December 2018 were retrospectively reviewed. All patients who continue to have signs of right ventricle strain after 3 days of VA-ECMO support underwent surgical embolectomy. <h3>Results</h3> Thirty-nine patients were identified; one patient underwent Surgical Embolectomy removal 4 days after support. The remaining 38 included, there were 22 (58%) males. Median age was 58 years (range 17-88), the mean support time was 4 days (range 1-10). Overall, 29 (76%) patients were successfully separated off ECMO, 3 patients underwent comfort care measures due to severe neurologic injury. Twenty (53%) patients were discharged from the hospital, 3 with mild or moderate right ventricle dysfunction, nineteen patients were alive after 6 months follow up all have normalized right ventricle function. Ten patients from the series received E-CPR at the time of initiation, 4 (40%) were separated from ECMO and three were discharged home. 28 patients underwent catheter-based therapy prior to ECMO or while on support, 5 received angiovac debulking prior to ECMO support. The major ECMO complications included 3 patients with vascular injury from ECMO placement and 3 with irreversible neurological injury and PA catheter rupture. <h3>Conclusion</h3> VA-ECMO support is an effective method of support for patients with massive PE and hemodynamic instability. It could be used as a first line of treatment in selected patients or could be used to stabilize the patient as bridge to alternative treatment.

Acute pulmonary embolism in COVID-19 pandemic: prevalence and intrahospital outcome: a single center experience

Abstract Funding Acknowledgements Type of funding sources: None. Purpose We want to evaluate clinical, laboratory profiles and intra-hospital outcome in patients with acute PE treated in intensive care unit in the period of COVID-19 pandemic. Methods This is a single center, retrospective cohort study of patients with confirmed acute PE admitted in Intensive Cardiac Care Unit of a tertiary level university hospital between January and December 2020. Detailed history, risk factors, laboratory parameters and treatment strategy based on patient risk were assessed. All patients underwent 2-dimensional echocardiography, lower limb venous Doppler and CT pulmonary angiography (CTPA). sPESI score and intra-hospital outcomes were evaluated in all patients. Nasopharyngeal smear and real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay was performed in order to confirm COVID-19 infection. Results We studied 47 patients with acute PE treated in our ICU, with mean age 58.6 ± 19.4 years. Eight patients (17%) had massive PE (central thrombus) and 39 (83%) had sub massive PE (subsegmental thrombus) confirmed by CTPA. Six patients (12,7%) had history of deep vein thrombosis (DVT), 3 patients (6,3%) had history of prior PE, 4 patients (8,5%) were operated within 3 months, 7 patients (14,8%) had history of malignancy, 24 patient’s had increased body weight and obesity (51%). Twelve patients (25,5%) were tested for COVID 19 with real-time reverse transcriptase–polymerase chain reaction (RT-PCR) assay, and 3 come positive (12.5%). Eight patients were high risk with shock (17%), intermediate high risk were 29 patients (61.7%) and intermediate low risk were 10 patients (21.3%). sPESI score was &amp;gt;1 in all 47 patients. Abnormal RV function with PAH was found in 32 patients (68%). Five high risk, unstable patients died within 72 hours of admission, resulting in an overall ICU mortality rate of 10,6% and 62.5% mortality rate in patients with cardiogenic shock. Patients with PE and COVID-19 had significantly higher D-dimer and hs-Troponin I levels comparing to the patients with patients negative for COVID-19. Multivariate logistic regression analysis showed thrombolytic therapy OR 2.145 (95% CI: 1.105−4,512), D-Dimers &amp;gt;4.500 ng/ml OR 1.893 (95% CI: 0.932–3.241), high risk PE OR 3.98 (95% CI: 1.396−5.641) and acute renal failure OR 2.421 (95% CI: 1.105−4.762) as independent mortality predictors. Eight patients have been treated with fibrinolysis (t-PA), and 39 patients with Heparin therapy. 40 survived patients were discharged with NOAC treatment (95,2%). Conclusions Pulmonary embolism cardiology clinic ICU admission in the period of COVID-19 pandemic decreased, with increase of PE severity, patients risk and mortality rate. Thrombolytic therapy, D-Dimers &amp;gt;4.500 ng/ml, high risk PE and acute renal failure were independent mortality predictors. Thrombolysis was successful treatment for high risk patients with low bleeding risk.