Massive Pulmonary Embolism Patients Research Articles

Survival Outcomes in Patients with Intermediate and High-Risk Pulmonary Embolism Treated with Low Molecular Weight or Unfractionated Heparin: Time to Start of Anticoagulant Therapy

Introduction Venous Thromboembolism (VTE), including pulmonary embolism (PE), is the third most common cause of vascular disease related death in the United States. If left untreated, the mortality of PE is as high as 30%. The main-stay of treatment for PE involves anticoagulant therapy (AT), commonly with low molecular weight heparin (LMWH), or unfractionated heparin (UFH). Prior data has demonstrated a reduction in mortality with anticoagulant timing. In one study, 30-day all-cause mortality was lower in patients who achieved therapeutic AT, as defined by activated partial thromboplastin time (aPTT), within 24 hours of ER presentation. However, recent data demonstrated low numbers of patients with therapeutic range aPTT at 24 hours (< 30%). Thus, we aimed to assess the association between time to anticoagulant therapy from emergency room (ER) presentation and 30-day PE-associated mortality. Methods We performed a retrospective cohort study of patients at Barnes Jewish Hospital between January 2021 and April 2023 for which the Pulmonary Embolism Response Team (PERT) was activated. Patients with intermediate-low, intermediate-high, or massive (high-risk) PE who presented to the emergency department or urgent care facility with signs/symptoms concerning for PE were included. PE was objectively confirmed on imaging studies (CT or VQ Scan). Only patients initiated on UFH or LMWH were included. Patient demographic and hemodynamic data were collected on presentation. Those with low-risk PE, those started on an AT other than UFH/LMWH, and those who died prior to the start of AT were excluded. Time from ER presentation (as estimated by triage vital signs) to start of AT was calculated based on review of the Electronic Medical Record. The primary outcome was PE-associated mortality within 30 days. PE-associated mortality was defined as: deaths directly caused by PE, deaths caused by the treatment of PE, and multifactorial deaths with PE as a contributing illness. Using logistic regression, we calculated the association between each doubling of the time until AT was given and PE-associated mortality. Results A total of 184 patients met inclusion criteria, 138 patients with intermediate-risk PE and 46 with massive PE. 81% of patients received UFH (n = 149) and 19% received LMWH (n = 35). PE-associated mortality occurred in 5.1% (n = 7) of patients in the intermediate-risk group and 32.6% (n = 15) in the high-risk group. The average time from ER triage to start of AT was 5 hours in intermediate-risk patients who survived versus 8.1 hours in those who died. The average time from ER triage to start of AT was 5.3 hours in massive PE patients who survived versus 5.4 hours in those who died. After adjusting for massive PE classification and sPESI score, each doubling of time in delay of AT from ER presentation was associated with 1.27 increased odds of PE-associated death (odds ratio (OR) 1.27, 95% confidence interval (CI) 0.85, 1.89) (Table 1). The discrimination of the model was very good with a c-statistic of 0.83 for prediction of PE-associated 30-day mortality. When only analyzing patients with intermediate-risk PE, each doubling of time in delay of AT from ER presentation was associated with 2.72 increased odds of PE-associated death (OR 2.72, 95% CI 1.11, 6.78) (Table 1). Conclusions In patients with intermediate-risk or massive PE, each doubling of the time from patient presentation to the ER to start of anticoagulant therapy was associated with 1.27 increased odds in the risk of PE-associated 30-day mortality. This association was more pronounced in patients with intermediate-risk PE. Future efforts should be aimed at decreasing time from ER presentation to start of anticoagulant therapy in patients with PE such as through quality improvement projects and/or triage protocolization.

Obstructive Shock Pulmonary Embolism: Catheter Directed Thrombolysis

Venous thromboembolism is one of the most frequently encountered condition for which patients need intensive care admission often. Most of the time patients presents with shock and hemodynamic instability if it is massive pulmonary embolism. Incidence of Vte is comparable to western population in India, studies conducted by Ayyapan et all say it around 20/10,000 admission. Studies showed higher mortality of around 50% in high risk (massive) and mortality of around 14% in intermediate risk (sub-massive) PE which necessitating more aggressive approach in high-risk groups. Rapid administration of systemic thrombolytic agents is indicated in massive pulmonary embolism patients who presents with hemodynamic instability but systemic thrombolytic therapy is associated with risk of major bleeding around 20% and haemorrhagic stroke of 2% to 5% . During systemic thrombolysis shunting of thrombolytic agents away from clot into the systemic circulation which makes it failed lysis sometimes along with major bleeding.

Comparison of the effectiveness of high-flow and conventional nasal cannula oxygen therapy in pulmonary embolism patients with acute hypoxemic respiratory failure.

The leading cause of mortality in pulmonary embolism (PE) is hypoxemic respiratory failure. The aim of this study was to compare the efficacy of high-flow nasal cannula (HFNC) and conventional nasal cannula (CNC) oxygen therapy in PE patients with hypoxemia. Fifty-eight patients with a PaO2/FIO2 ratio below 300 who were admitted to the emergency department with acute respiratory distress and followed up in our intensive care unit due to PE between March and October 2019 were included in the study. One group (n= 29) received HFNC oxygen therapy and the other group (n= 29) received CNC oxygen therapy. Arterial blood gas analysis showed no significant differences in baseline SpO2 and PaO2 between the HFNC and CNC groups, whereas both values were significantly higher in the HFNC group starting at 1 hour (PaO2: p= .01, p= .001, p= .001; SpO2: p= .009, p= .005, p= .002). Among massive PE patients with contraindications for thrombolytic therapy, there was no significant difference between the HFNC and CNC groups in baseline SpO2, PaO2, or respiratory rate, but those who received HFNC therapy had significant higher SpO2 starting at 15 minutes (p= .004 for all), significantly higher PaO2 starting at 1 hour (p= .01, p= .001, p= .001), and significantly lower respiratory rate starting at 30 minutes (p= .003, p= .001, p= .001, p= .002, p= .002). In patients presenting with PE and hypoxemic respiratory failure, HFNC oxygen therapy was more effective on both vital signs and arterial blood gas parameters compared to conventional oxygen therapy and can be used safely as primary treatment.

Clinical outcomes of acute pulmonary embolectomy as the first-line treatment for massive and submassive pulmonary embolism: a single-centre study in China

BackgroundAcute pulmonary embolism (PE) is one of the most critical cardiovascular diseases. PE treatment ranges from anticoagulation, and systemic thrombolysis to surgical embolectomy and catheter embolectomy. Surgical pulmonary embolectmy (SPE) indications and outcomes are still controversial. Although there have been more favourable SPE reports over the past decades, SPE has not yet been considered broadly as an initial PE therapy and is still considered as a reserve or rescue treatment for acute massive PE when systemic thrombolysis fails. This study aimed to evaluate the early and midterm outcomes of SPE, which was a first-line therapy for acute central major PE in one Chinese single centre.MethodsA retrospective review of patients who underwent SPE for acute PE was conducted.Patients with chronic thrombus or who underwent thromboendarterectomy were excluded. SPE risk factors for morbidity and mortality were reviewed, and echocardiographic examination were conducted for follow-up studies to access right ventricular function.ResultsOverall, 41 patients were included; 17 (41.5%) had submassive PE, and 24 (58.5%) had massive PE. Mean cardiopulmonary bypass time was 103.2 ± 48.9 min, and 10 patients (24.4%) underwent procedures without aortic cross-clamping. Ventilatory support time was 78 h (range, 40–336 h), intensive care unit stay was 7 days (range, 3–13 days), and hospital stay was 16 days (range, 12–23 days). Operative mortalities occurred in 3 massive PE patients, and no mortality occurred in submassive PE patients. The overall SPE mortality rate was 7.31% (3/41). If two systemic thrombolysis cases were excluded, SPE mortality was low (2.56%,1/39), evenlthough there were 2 cases of cardiac arrest preoperatively. Patients’ right ventricle function improved postoperatively in follow-ups.There were no deaths related to recurrent PE and chronic pulmonary hypertension in follow-ups, though 3 patients died of cerebral intracranial bleeding, gastric cancer,and brain cancer at 1 year, 3 years, and 8 years postoperatively, respectively.ConclusionsSPE presented with a low mortality rate when rendered as a first-line treatment in selected massive and submassive acute PE patients. Favorable outcomes of right ventricle function were also observed in the follow-ups. SPE should play the same role as ST in algorithmic acute PE treatment.

Massive pulmonary embolism in patients with extreme bleeding risk: a case series on the successful use of ultrasound-assisted, catheter directed thrombolysis in a district general hospital

Massive pulmonary embolism (PE), characterised by profound arterial hypotension, is a life-threatening emergency with a 90-day mortality of over 50%. Systemic thrombolysis can significantly reduce the risk of death or cardiovascular collapse in these patients, by around 50%, but these benefits are offset by a fivefold increased risk of intracranial haemorrhage and major bleeding, which may limit its use in patients at high risk of catastrophic haemorrhage. We describe a case series of 3 patients presenting with massive PE, each with extreme risk of bleeding and contra-indication to systemic thrombolysis, treated successfully with ultrasound-assisted, catheter directed thrombolysis (U-ACDT). Our experience of this novel technique using the EkoSonic Endovascular System (Ekos, BTG, London, UK) on carefully selected patients has demonstrated the potential to improve clinical status in shocked patients, with minimal bleed risk. There have been several clinical studies evaluating the Ekos system. Both the ULTIMA and SEATTLE II studies have shown significant reductions in RV/LV ratio by CT scanning when compared to standard anticoagulation in patients with intermediate-risk PE, with minimal bleeding complications. However, there is a pressing need for a randomised trial demonstrating improvement in robust clinical outcomes when comparing U-ACDT to simple anticoagulation. We believe that this case series adds new insight and highlights the potential of catheter directed thrombolysis in this high-risk patient cohort and consideration should be made to its use in cases where systemic thrombolysis is felt to be too high risk.

Rescue catheter-based therapies for the treatment of acute massive pulmonary embolism after unsuccessful systemic thrombolysis.

The management of acute massive pulmonary embolism (PE) patients who did not respond to systemic thrombolysis (ST) has not been well established. The present study aimed to investigate the safety and effectiveness of catheter-based therapies (CDT) in this condition. We conducted a retrospective study of PE patients after unsuccessful ST (UST) between January 2012 and January 2018. Massive PE was identified in 408 patients and treated with full-dose ST therapy. Thrombolysis at 36h was judged to be unsuccessful in 52 patients. Four ineligible patients were excluded, and the remaining 48 patients underwent rescue CDT: 30 patients underwent thrombus fragmentation with a rotating pigtail catheter; 8 patients underwent Straub rotational thrombectomy; and 10 patients underwent AngioJet rheolytic thrombectomy. In total, 42 patients subsequently underwent CDT relative to reduced-dose thrombolysis. Pooled clinical success was achieved in 45 patients, and the time-to-clinical instability relief for CDT was short (i.e., 48h). Clinical findings significantly improved with oxygen saturation and the shock index (p < 0.01). CDT resulted in a significant decrease in the right ventricular (RV)/left ventricular end-diastolic diameter ratio and the average number of patients with pulmonary hypertension (p < 0.01). None of the patients suffered major complications or procedure-related adverse events, and two patients experienced minor complications. During follow-up, RV function symptoms were uneventful. The present study found that CDT is a safe and effective modality for rescue management of massive PE in patients with clinical instability and RV dysfunction after UST, leading to improved clinical outcomes and RV function with a low complication rate.

Pediatric Massive and Submassive Pulmonary Embolism: A Single-Center Experience.

To describe and compare patient and event characteristics and outcomes in pediatric massive pulmonary embolism (MPE) and submassive pulmonary embolism (SMPE). A retrospective cohort study at a quaternary-care pediatric hospital was conducted. Patients age <19 years with MPE (acute pulmonary embolism [PE] with cardiac arrest, hypotension, or compensated shock due to PE) or SMPE (right ventricular strain due to acute PE) between January 1997 and June 2019 were included. Thirty-three patients were identified, including 9 (27%) patients with MPE and 24 (73%) patients with SMPE. The most commonly identified risk factor was use of oral contraceptive pills in 16 (49%) patients. Six (18%) patients died, 3 (9%) of which were PE-related deaths. Before PE, patients with MPE were more likely to be hospitalized (89% vs 13%, P < .001), have major comorbidities (89% vs 25%, P = .002), central venous catheters (67% vs 17%, P = .01), critical illness (56% vs 8%, P = .009), immobility (67% vs 13%, P = .005), and be postoperative (44% vs 4%, P = .01). MPE patients were also more likely to die before discharge (56% vs 4%, P = .003). Both groups were equally likely to have primary reperfusion attempts (78% of MPE versus 67% of SMPE, P = .69). Pediatric MPE and SMPE differed in presentation, comorbidities, and risk factors, many of which were associated with hospitalization status. Pediatric-specific studies are warranted to determine risk assessment and management strategies, which may differ from adult guidelines.

SUBMASSIVE PULMONARY EMBOLISM IN THE SETTING OF HEPARIN-INDUCED THROMBOCYTOPENIA

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Heparin-induced Thrombocytopenia (HIT) is an immunoglobulin-mediated response against platelet factor 4-heparin complexes leading to thrombotic events carrying a mortality rate of 5-10%. HIT with pulmonary embolism (PE) although rare, is the most common life-threatening event occurring in 25% of all HIT cases. Treatment is controversial as heparin products are contraindicated and no best practices have been described. We present a case of a middle-age man with recent exposure to heparin presenting with syncope. CASE PRESENTATION: A 54 year-old male with type 2 diabetes and a recent hospitalization 10 days prior for diabetic ketoacidosis receiving prophylactic heparin presented for syncope. On arrival he was normotensive but tachycardic and hypoxemic. Laboratory studies revealed thrombocytopenia to 90k, a drop from baseline 150k, which was confirmed by repeat testing. Troponin and BNP were elevated. Electrocardiogram revealed sinus tachycardia and S1Q3T3 pattern. Given concern for submassive PE patient was started on a heparin drip since confirmatory computer tomography angiography could not be performed due to renal failure. Cardiology was consulted for possible catheter directed tissue plasminogen activator or thrombectomy, however both these interventions were unavailable at our institution. Given suspicion of HIT patient was switched from heparin to argatroban drip. Ventilation/perfusion scan demonstrated high probability of bilateral PE and transthoracic echocardiogram revealed right heart strain. Dopplers confirmed popliteal and left brachial vein thrombosis. Patient’s platelet count improved after discontinuation of heparin products to 140k. Platelet factor 4 and serotonin release assay were both positive. The patient was eventually transitioned to warfarin to be continued for 3 months and then re-evaluated. DISCUSSION: Treatment of submassive and massive PE in patients with HIT remains controversial. Several modalities of treatment have been described in the literature with varied success including non-heparin anticoagulation like argatroban, thrombolytic agents, catheter-based thrombus aspiration, and surgical embolectomy. Multiple cases using direct thrombin inhibitors like danaparoid, bivalirudin, lepirudin and argatroban have been reported however given argatroban is hepatically cleared, it tends to be used the most. Hemodynamic stability continues to be the prime factor when deciding between parenteral anticoagulation versus more invasive techniques. In the setting of HIT-associated PE with significant hemodynamic compromise, non-heparin anticoagulation with catheter-directed thrombolysis has been used with good outcomes. CONCLUSIONS: HIT associated PE is a rare phenomenon, however, when it occurs there are available treatment options. Although no clear study has demonstrated superiority, treatment primarily depends on hemodynamic stability and institutional resources. Reference #1: Mark Prince, Tim Wenham. “Heparin-induced thrombocytopenia” Postgraduate Medical Journal, Volume 94, Issue 1114 Reference #2: Hourmouzis, Z., et al. (2015). "Pulmonary embolism and heparin-induced thrombocytopenia successfully treated with tissue plasminogen activator and argatroban.” Am J Emerg Med 33(5): 739 e735-736 Reference #3: Warkentin TE, Kelton JG. “A 14-year study of heparin-induced thrombocytopenia” Am J Med. 1996;101(5):502 DISCLOSURES: No relevant relationships by Ayesha Azmeen, source=Web Response No relevant relationships by Anil Magge, source=Web Response no disclosure on file for Viraj Modi; No relevant relationships by Mario Perez, source=Web Response

The Results of Thrombolytic Treatment in Patients With High-risk Pulmonary Embolism

Abstract Background: Mortality rates due to massive pulmonary embolism (PE) are much higher than estimated. Although thrombolytic therapy is controversial, it can be a life-saving procedure and can be safely used in patients with massive PE. Study aim: We aimed to share the results of thrombolytic treatment in patients with massive PE. Material and methods: We retrospectively evaluated 72 patients with PE admitted between January 2010 and April 2018 to the Department of Pulmonary Medicine, VM Medicalpark Samsun Hospital, Samsun, Turkey. The data of patients who received thrombolytic treatment were retrospectively analyzed. Results: The female to male ratio was 24/48, with a mean age of 62.7 ± 12.6 (minimum 27, maximum 88) years. The diagnosis of massive PE was established with echocardiography in all patients and was confirmed via pulmonary CT angiography in 45 patients (62.5%) who presented an appropriate clinical status for this imaging technique. The most common symptoms were dyspnea (90.3%), chest pain (83.3%), and syncope (40.2%). The S1Q3T3 electrocardiography pattern was noted in 82% of patients, who rapidly recovered after thrombolytic therapy. Cardiopulmonary arrest was seen in 25 patients (37.2%), and thrombolytic treatment was administered during cardiopulmonary resuscitation in 18% (n = 13) of patients. The survival rate was 30.7% (n = 4) in patients with cardiopulmonary arrest who received thrombolytic treatment in the emergency room. The complications of rt-PA treatment included minor hemorrhages in 6.4% (n = 5), major hemorrhages in 2.7% (n = 2), and allergic reactions in 1.3% (n = 1) of patients. None of the patients had deceased as a complication of thrombolytic treatment. The overall mortality rate was 26.2% (n = 19), and 12.5% (n = 9) of the patients have died in first 24 hours after thrombolysis. Conclusions: We concluded that the risk factors, ECG, and echocardiography are key indicators for the suspicion of massive PE in patients with hemodynamic shock. Based on our experience, early thrombolytic therapy is a life-saving intervention in patients with diagnosed and/or suspected massive PE.

Assessing the Impact of a Pulmonary Embolism Response Team and Treatment Protocol on Patients Presenting With Acute Pulmonary Embolism

Pulmonary embolism (PE) care has traditionally been fragmented. The newly introduced Pulmonary Embolism Response Team (PERT) model provides streamlined care based on expedient, multi-disciplinary decision-making. This study aimed to quantify the impact of PERT, as part of a hospital-wide PE treatment protocol, on clinical outcomes. Consecutive adult patients with acute PE diagnosed via computed tomography pulmonary angiogram (CTPA) were included. The PERT and treatment protocol were introduced in January 2015. Patient characteristics, therapies, quality measures of CTPA reporting, and clinical outcomes of PE patients treated for 2 years before and after implementation of these changes were evaluated. Primary endpoints were median length of stay in intensive care (ICU) and survival to discharge. A total of 321 consecutive PE patients were enrolled, of which 154 (treated in 2013-2014) and 167 (2015-2016) patients formed the historical control and study groups, respectively. Implementation of the algorithm was associated with less variance in anticoagulation and improved reporting of right heart strain parameters on CTPA. The ICU stay was reduced from a median of 5 to 2 days (p < 0.01). Eligible massive PE patients receiving reperfusion increased from 30% to 92% (p = 0.01), with mean delay from diagnosis to reperfusion decreasing from 763 to 181 minutes (p < 0.01). Bleeding complications were not increased, but overall survival to discharge remained unchanged. Introducing a PERT and treatment protocol reduced ICU stay, enhanced quality measures, and improved access of massive PE patients to reperfusion therapies, without increasing bleeding complications or health care costs.

PRESENTATION, THERAPY, AND OUTCOMES OF PATIENTS WITH MASSIVE PULMONARY EMBOLISM IN THE MODERN ERA

Published data regarding presentation, therapy, and outcomes of patients with massive pulmonary embolism (PE) are outdated and may be obsolete, given advances in treatment options and intensive care. A prospective database of submassive and massive PE patients treated by a multidisciplinary team at

Abstract 23080: Increased Pulmonary Peripheral (But Not Central) Blood Flow Correlates With Decreased Right Ventricular Volume in Acute Pulmonary Embolism Treated With Ultrasound-Facilitated, Catheter-Directed Fibrinolysis

Introduction: Ultrasound-facilitated, catheter-directed fibrinolysis improves right ventricular (RV) function in patients with acute pulmonary embolism (PE). Resolution of central pulmonary arterial thrombotic obstruction has been hypothesized as the principal mechanism for RV recovery. Hypothesis: We postulated that improved peripheral blood flow rather than central blood flow correlates with reversal of RV enlargement due to PE. Methods: Using a 3-dimensional quantitative reconstruction technique that allows resolution of the distal pulmonary arteries, we analyzed the computed tomographic (CT) pulmonary angiograms of 60 submassive and massive PE patients treated with ultrasound-facilitated, catheter-directed, low-dose fibrinolysis. We correlated the change in blood volume of the pulmonary arteries (&lt;10 mm 2 vs. &gt;40 mm 2 cross sectional area) from baseline to 48 ± 6 hours with change in CT-measured RV volume. Results: Forty-five patients demonstrated reduction in RV volume (mean change was -31 ml). Increase in total lung blood volume/lung volume correlated with decreased RV volume/lung volume (R 2 = 0.26). RV volume-to-left ventricular volume ratio decreased by 26% ( Figure, Panel A ). Decreased RV volume correlated with increased blood volume through &lt;10 mm 2 pulmonary arteries (R 2 = 0.28) but not larger pulmonary arteries (&gt; 40 mm 2 ) (R 2 = 0.00003) ( Figure, Panel B1 and B2 ). Conclusion: Total lung blood volume increases following ultrasound-facilitated, catheter-directed fibrinolysis. Increased blood volume through the peripheral, but not central, pulmonary artery vasculature correlates with reduction in RV volume after ultrasound-facilitated catheter-directed fibrinolysis.

Life-threatening massive pulmonary embolism rescued by venoarterial-extracorporeal membrane oxygenation

BackgroundDespite quick implementation of reperfusion therapies, a few patients with high-risk, acute, massive, pulmonary embolism (PE) remain highly hemodynamically unstable. Others have absolute contraindication to receive reperfusion therapies. Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) might lower their right ventricular overload, improve hemodynamic status, and restore tissue oxygenation.MethodsECMO-related complications and 90-day mortality were analyzed for 17 highly unstable, ECMO-treated, massive PE patients admitted to a tertiary-care center (2006–2015). Hospital- discharge survivors were assessed for long-term health-related quality of life. A systematic review of this topic was also conducted.ResultsSeventeen high-risk PE patients [median age 51 (range 18–70) years, Simplified Acute Physiology Score II (SAPS II) 78 (45–95)] were placed on VA-ECMO for 4 (1–12) days. Among 15 (82%) patients with pre-ECMO cardiac arrest, seven (41%) were cannulated during cardiopulmonary resuscitation, and eight (47%) underwent pre-ECMO thrombolysis. Pre-ECMO median blood pressure, pH, and blood lactate were, respectively: 42 (0–106) mmHg, 6.99 (6.54–7.37) and 13 (4–19) mmol/L. Ninety-day survival was 47%. Fifteen (88%) patients suffered in-ICU severe hemorrhages with no impact on survival. Like other ECMO-treated patients, ours reported limitations of all physical domains but preserved mental health 19 (4–69) months post-ICU discharge.ConclusionsVA-ECMO could be a lifesaving rescue therapy for patients with high-risk, acute, massive PE when thrombolytic therapy fails or the patient is too sick to benefit from surgical thrombectomy. Because heparin-induced clot dissolution and spontaneous fibrinolysis allows ECMO weaning within several days, future studies should investigate whether VA-ECMO should be the sole therapy or completed by additional mechanical clot-removal therapies in this setting.

PERIPHERAL ANATOMIC DISTRIBUTION OF THROMBUS DOES NOT ADVERSELY AFFECT OUTCOMES IN PATIENTS UNDERGOING SURGICAL PULMONARY EMBOLECTOMY FOR SUBMASSIVE AND MASSIVE PULMONARY EMBOLISM

Background: Thrombus located distal to the primary pulmonary arteries has been previously viewed as a relative contraindication to surgical pulmonary embolectomy. We compared outcomes for surgical pulmonary embolectomy for submassive and massive pulmonary embolism in patients with central vs

Non-Invasive Imaging of Lung Remodeling and Right Ventricle Metabolic Shift in an Animal Model of Pulmonary Hypertension

Massive pulmonary embolism (MPE) is a significant cause of mortality and, with submassive pulmonary embolism (SPE), is associated with chronic thromboembolic pulmonary hypertension, resulting in ongoing patient morbidity. Standard treatment is anticoagulation, although systemic thrombolytic therapy has been shown to reduce early mortality in patients with MPE and improve cardiopulmonary hemodynamics in patients with SPE. However, systemic lysis is associated with significant bleeding risk. Early reports of catheter-directed techniques (CDT) suggest favorable outcomes in patients with MPE and SPE with reduced risk of hemorrhage. The purpose of this study is to evaluate efficacy and safety outcomes in MPE and SPE patients treated with CDT.Seventeen patients treated with CDT for MPE and SPE were clinically and hemodynamically evaluated. Patients were grouped by severity of pulmonary embolism: MPE (n = 5) or SPE (n = 12). Pre- and post-interventional measures were assessed, including pulmonary artery pressures (PAPs), cardiac biomarkers, tricuspid regurgitation, right ventricular (RV) dilatation, and systolic function. Nine patients had contraindications to systemic thrombolytic therapy.PAP was elevated in 94% at presentation. The average dose of recombinant tissue plasminogen activator (rt-PA) was 31 mg; 44 mg in MPE and 26 mg in SPE. Pre- and post-intervention PAPs were recorded in 13 patients. All demonstrated an acute reduction in posttreatment PAP, averaging 37%. At presentation, all MPE and 10 (83%) SPE patients showed both RV dilatation and reduced function on echocardiography, which normalized in 76% (13/17) and improved in 24% (4/17) after CDT. Patients who demonstrated left ventricle underfilling before CDT (2 [40%] MPE and 2 [20%] SPE) normalized after CDT. All MPE and 11 (92%) SPE patients had tricuspid regurgitation on echocardiography pretreatment, which resolved in 60% and 58% of MPE and SPE patients, respectively. One delayed mortality occurred in an MPE patient who was hypotensive and hypoxic at presentation. There was one puncture site bleed.CDT was successful in the acute management of patients with MPE and SPE. CDT rapidly restores cardiopulmonary hemodynamics using reduced doses of rt-PA. These observations suggest that CDT should be considered in MPE and SPE patients to rapidly restore cardiopulmonary hemodynamics, reduce acute morbidity and mortality, reduce bleeding complications, and potentially avoid long-term morbidity.

Catheter-Directed Thrombolytic Intervention Is Effective for Patients with Massive and Submassive Pulmonary Embolism

Massive pulmonary embolism (MPE) is a significant cause of mortality and, with submassive pulmonary embolism (SPE), is associated with chronic thromboembolic pulmonary hypertension, resulting in ongoing patient morbidity. Standard treatment is anticoagulation, although systemic thrombolytic therapy has been shown to reduce early mortality in patients with MPE and improve cardiopulmonary hemodynamics in patients with SPE. However, systemic lysis is associated with significant bleeding risk. Early reports of catheter-directed techniques (CDT) suggest favorable outcomes in patients with MPE and SPE with reduced risk of hemorrhage. The purpose of this study is to evaluate efficacy and safety outcomes in MPE and SPE patients treated with CDT. Seventeen patients treated with CDT for MPE and SPE were clinically and hemodynamically evaluated. Patients were grouped by severity of pulmonary embolism: MPE (n=5) or SPE (n=12). Pre- and post-interventional measures were assessed, including pulmonary artery pressures (PAPs), cardiac biomarkers, tricuspid regurgitation, right ventricular (RV) dilatation, and systolic function. Nine patients had contraindications to systemic thrombolytic therapy. PAP was elevated in 94% at presentation. The average dose of recombinant tissue plasminogen activator (rt-PA) was 31mg; 44mg in MPE and 26mg in SPE. Pre- and post-intervention PAPs were recorded in 13 patients. All demonstrated an acute reduction in posttreatment PAP, averaging 37%. At presentation, all MPE and 10 (83%) SPE patients showed both RV dilatation and reduced function on echocardiography, which normalized in 76% (13/17) and improved in 24% (4/17) after CDT. Patients who demonstrated left ventricle underfilling before CDT (2 [40%] MPE and 2 [20%] SPE) normalized after CDT. All MPE and 11 (92%) SPE patients had tricuspid regurgitation on echocardiography pretreatment, which resolved in 60% and 58% of MPE and SPE patients, respectively. One delayed mortality occurred in an MPE patient who was hypotensive and hypoxic at presentation. There was one puncture site bleed. CDT was successful in the acute management of patients with MPE and SPE. CDT rapidly restores cardiopulmonary hemodynamics using reduced doses of rt-PA. These observations suggest that CDT should be considered in MPE and SPE patients to rapidly restore cardiopulmonary hemodynamics, reduce acute morbidity and mortality, reduce bleeding complications, and potentially avoid long-term morbidity.

C0590: Managment of Massive Pulmonary Embolism in Patients with Acute Intracranial Bleeding

C0590: Managment of Massive Pulmonary Embolism in Patients with Acute Intracranial Bleeding

A Case of Pulmonary Embolism Due to Metastatic Chondrosarcoma

폐동맥 í˜ˆì „ìƒ‰ì „ì¦ìœ¼ë¡œ 내원하는 환자에서 í•­í˜ˆì „ì¹˜ë£Œ 및 í•­ì‘ê³ ì¹˜ë£Œ 시행 이후 치료 효과에 대한 ì ì ˆí•œ 평가가 필요하며, 치료에 대한 ì ì ˆí•œ 반응을 보이지 않을 경우, ì¢ ì–‘ ìƒ‰ì „ì¦ 등의 다른 원인에 대한 ê·œëª ì´ í•„ìš”í• ê²ƒìœ¼ë¡œ 사료된다. 중심 단어: 폐 ìƒ‰ì „ì¦; ì „ì´ì„± 연골육ì¢

Thrombolysis in Pulmonary Embolism

The standard therapy for acute pulmonary embolism is initiated with heparin. Massive pulmonary embolism (PE) is defined by the presence of cardiogenic shock, persistent arterial hypotension, or both. It is associated with a high risk of in-hospital death, particularly during the first hours after admission. Thrombolysis is recommended in massive PE. Results from a randomized trial suggested that selected patients with evidence of right ventricular dysfunction and a low risk of bleeding may benefit from thrombolysis. In this issue of the Journal, Kim Yang-Ki and colleagues conducted retrospective review of thrombolytic therapy in PE last 6.5 years in a single center. The mortality rate of massive PE (44%) was higher than submassive PE (8%) in patients with thrombolysis. Major bleeding occurred in 3/21 (14%) patients. This signal reminds us “real-world” hazards of thrombolysis is higher than randomized controlled trial. Although massive PE patients need more intensifying therapy to reduce mortality, we should careful assessment of bleeding risk factors before starting thrombolysis. With regard to submassive PE, this study has limitation to assessing the efficacy of thrombolysis. (Korean J Med 2013;84:46-48) Keywords: Pulmonary embolism; Thrombolysis; Bleeding

Rheolytic thrombectomy in patients with massive pulmonary embolism: A report of two cases and review of literature

We present two cases of massive pulmonary embolism with persistent systolic hypotension but both have contraindications for thrombolysis. Therefore, rheolytic thrombectomy using AngioJet was performed and immediate haemodynamic improvement was achieved including blood pressure and symptoms. According to guidelines, catheter embolectomy or fragmentation may be considered as alternative to surgical treatment in massive pulmonary embolism patients when thrombolysis is absolutely contraindicated or has failed. Percutaneous catheter-based interventional techniques include thrombus fragmentation, rheolytic thrombectomy, suction thrombectomy and rotational thrombectomy. With the existing literature review and our case, rheolytic thrombectomy for treatment of massive pulmonary embolism using AngioJet achieves a high procedural success rate (approximately 90%) n terms of improvement of haemodynamics, pulmonary perfusion and angiographic result but low complication rate.