Saddle Pulmonary Embolism Research Articles

Management of Saddle Pulmonary Embolism in the Context of Heparin-Induced Thrombocytopenia and Granulomatosis With Polyangiitis

Management of Saddle Pulmonary Embolism in the Context of Heparin-Induced Thrombocytopenia and Granulomatosis With Polyangiitis

Perioperative Management and Outcomes after Endovascular Mechanical Thrombectomy in Patients with Submassive (Intermediate-Risk) Pulmonary Embolism: A Retrospective Observational Cohort Study.

Pulmonary embolism (PE) embodies a large healthcare burden globally and is the third leading cause of morbidity and mortality worldwide. Submassive (intermediate-risk) PE accounts for 40% of this burden. However, the optimal treatment pathway for this population remains complex and ill-defined. Catheter-directed interventions (CDIs) have shown promise in directly impacting morbidity and mortality while demonstrating a favorable success rate, safety profile, and decreased length of stay (LOS) in the intensive care unit and hospital. This retrospective review included 22 patients (50% female) with submassive PE who underwent mechanical thrombectomy (MT). A total of 45% had a contraindication to thrombolytics, the mean pulmonary embolism severity index was 127, 36% had saddle PE, the average decrease in mean pulmonary artery pressure (PAP) was 7.2 mmHg following MT, the average LOS was 6.9 days, the 30-day mortality rate was 9%, the major adverse event (MAE) rate was 9%, and the readmission rate was 13.6%. A total of 82% had successful removal of thrombus during MT with no major bleeding complications, intracranial hemorrhage events, or device-related deaths. Acknowledging the limitation of our small sample size, our data indicate that MT in the intermediate-high-risk submassive pulmonary embolism (PE) cohort resulted in a decreased hospital length of stay (LOS) and in-hospital mortality compared to standard anticoagulation therapy alone.

Evaluating the hemodynamic impact of saddle versus non-saddle pulmonary embolism: insights from a thrombectomy cohort.

The aim of this study was to compare the hemodynamic impact and clinical outcomes of saddle vs non-saddle pulmonary embolism (PE). This was a retrospective analysis of clinical characteristics and outcomes among patients with saddle and non-saddle PE within a cohort referred for catheter-based thrombectomy (CBT) with invasive hemodynamic assessments. Patients who underwent CBT between August 2020 and January 2024 were included. The primary outcome was the proportion of patients with a low cardiac index (CI < 2.2 L/min/m²). Secondary outcomes included 30-day mortality, intensive care unit (ICU) length of stay (LOS), and hospital LOS. A total of 107 patients (84 intermediate risk, 23 high-risk; mean age 58 years, 47.6% female) were included in the study, with 44 patients having saddle PE and 63 having non-saddle PE. There were no significant differences in baseline demographics and clinical characteristics between saddle and non-saddle PE, including rates of high-risk PE (25% vs 16%, P = .24), rates of RV dysfunction, pulmonary artery systolic pressure (55 vs 53 mm Hg, P = .74), mean pulmonary artery pressure (34 mm Hg vs 33 mm Hg), low cardiac index (56% vs 51%, P = .64), rates of normotensive shock (27% vs 20%, P = .44), or Composite Pulmonary Embolism Shock scores (4.5 vs 4.7, P = .25). Additionally, 30-day mortality (6% vs 5%, P = .69), ICU LOS, and hospital LOS were similar between the groups. Among patients undergoing CBT, there were no significant differences in invasive hemodynamic parameters or clinical outcomes between those with saddle and non-saddle PE.

Clinical decompensation after trauma laparotomy: It's probably not a pulmonary embolus

Introduction Computed Tomography (CT) to rule out pulmonary embolus (PE) is often ordered during post-trauma laparotomy clinical decompensation (CD) involving fever, tachycardia, tachypnea, and/or leukocytosis. We hypothesize this diagnostic modality is low-yield in the postoperative period when surgery-related sequelae are more probable.Methods This is a single-center retrospective cohort study of patients who underwent trauma laparotomy and had subsequent CT for CD from March 19, 2019 to June 30, 2022. Descriptive statistics and multiple logistic regression were performed. The primary outcome was saddle and lobar PE incidence.Results 1032 adult patients underwent trauma laparotomy with 434 undergoing CT for CD: 137 CT abdomen and pelvis only, 30 CTPE, 265 both. The majority (80.2 %) was male, age 33[interquartile range (IQR) 24–45], suffered penetrating mechanism (57 %), and had ISS 23[IQR16–30]. Injuries at laparotomy included 47 % solid organ, 62 % GI tract, 7 % biliary, 11 % vascular, and 42 % other. 176 (41 %) required damage control laparotomy. Median time to CT post-laparotomy was 174 h [111–235] with saddle and lobar PE in 3 (1 %), peripheral PE 18 (5 %), and abdominal abscess, leak, fluid, or pseudoaneurysm in 222 (51 %). Clinical management was altered (40 %) by antibiotics, therapeutic anticoagulation, drainage, aspiration, filter, thrombectomy, or surgical operation. Patients for whom CT findings changed management were more likely to have had GI tract surgery (69% vs 57 %, p = 0.021), higher white blood cell (WBC) (16.4 [13.1–20.5] vs 15.1 [9.9–19.5], p = 0.002), more hours between CT and laparotomy (184 [141–245] vs 162 [89–230], p = 0.002), and lower mortality (2% vs 8 %, p = 0.008). In-hospital mortality was 5 %; none were PE-related. Predictors of clinical intervention required based on CT imaging were GI tract injury (AOR: 1.65, p = 0.0182), and elevated WBC (AOR: 1.038, p = 0.010Conclusion Saddle and lobar PE incidence post-trauma laparotomy is low. SIRS-type symptoms prompting postoperative CT commonly have no procedural or antibiotic requirement. Postoperative decompensation is more likely related post-operative complications, and less likely a PE.

Electrocardiogram Signal Analysis With a Machine Learning Model Predicts the Presence of Pulmonary Embolism With Accuracy Dependent on Embolism Burden

ObjectiveTo develop an artificial intelligence deep neural network (AI-DNN) algorithm to analyze 12-lead electrocardiogram (ECG) for detection of acute pulmonary embolism (PE) and PE categories. Patients and MethodsA cohort of patients seen between January 1, 1999, and December 31, 2020, from across the Mayo Clinic Enterprise with computed tomography pulmonary angiogram (CTPA) and ECG performed ±6 hours was identified. Natural language processing algorithms were applied to radiology reports to determine the diagnosis of acute PE, acute right ventricular strain pulmonary embolism (RVSPE), saddle pulmonary embolism (SADPE), or no PE. Diagnostic performance parameters of the AI-DNN reported were area under the receiver operating characteristics curve (AUROC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). ResultsA cohort of patients with CTPA report and ECG consisted of 79,894 patients including 7423 (9.3%) with acute PE, among whom 1138 patients had RVSPE or SADPE. Artificial intelligence deep neural network predicted acute PE with a modest accuracy of AUROC of 0.69 (95% CI, 0.68-0.71), sensitivity of 63.5%, specificity of 64.7%, PPV of 15.6%, and NPV of 94.5%. The AI-DNN prediction using the same algorithm for RVSPE or SADPE was higher (AUROC, 0.84; 95% CI, 0.81-0.86) with a sensitivity of 80.8%, specificity of 64.7.8%, PPV of 3.5%, and NPV of 99.5%. ConclusionAn AI-based analysis of 12-lead ECG shows modest detection power for acute PE in patients who underwent CTPA, with higher accuracy for high-risk PE. Moreover, with the high NPV, it has the clinical potential to exclude high-risk PE quickly and correctly.

Saddle Pulmonary Embolus Treated With Bilateral Emergent Aspiration Pulmonary Thrombectomy

A 77 year old man with recurrent lower extremity thrombosis presented with acute onset shortness of breath and new onset hypoxemia three days after prostatectomy for adenocarcinoma of the prostate. He had been off anticoagulation during the perioperative period. In addition to his new diagnosis of prostate cancer he also had a remote history of treated non-invasive melanoma. Based on this presentation he was at high risk of developing thromboembolic disease. Computed tomography angiogram (CTA) of his chest confirmed a large saddle pulmonary embolus, echocardiogram was positive for new right ventricular wall motion dyskinesis and lower extremity ultrasound revealed bilateral acute and chronic deep vein thrombosis. Given his high bleeding risk, hypoxia and elevated troponin I, he underwent emergent successful aspiration pulmonary thrombectomy. This case is of interest to hospitalists and intesivists as it provides an overview of the current invasive management of pulmonary embolus in the acute setting when systemic anticoagulation is contraindicated. Emergent Aspiration Pulmonary Thrombectomy can restore pulmonary artery flow and cardiopulmonary hemodynamics. A collaborative team based approach that involves the emergency department, intensive care unit, interventional teams and hospitalists is favored.

SADDLE PULMONARY EMBOLISM: A RARE CASE OF PROXIMAL PULMONARY EMBOLISM

Saddle pulmonary embolism is defined as the presence of a visible thrombus located at the bifurcation of the pulmonary artery trunkshowing an aspect of saddle on a chest contrasted tomography scan. This is a rare case occurring in only 5.2% of patients with pulmonary embolism. (1)We report the case of a 93-year-old female patient who had no thrombo-embolic past medical history, she had got the gall bladder operation 25 years ago. The patient was admitted for a dyspnea associated with a chest pain and desaturation related to a pulmonary embolism confirmed on a chest contrasted tomography scan that has shown a typical aspect of saddle pulmonary embolism. Our patient was stable on hemodynamic state and had a high intermediate prognostic risk score. She was managed at the cardiac intensive care unit with anticoagulation that improved her clinically.

A Saddle Pulmonary Embolism at Transthoracic Echocardiography: A Case Report

Acute Pulmonary embolism (PE) is a life-threatening disease and is considered the third major cause of cardiovascular death with higher incidence and mortality rates. Identifying a saddle PE between the left and the right pulmonary trunk in transthoracic echocardiography (TTE) is rare, and helps to make a rapid diagnosis to avoid complications. Clinical presentation, electrocardiogram, and X-ray guide the diagnosis but are not specific. TTE is helpful and confirms the diagnosis especially when the CT is not available or in other situations when it is not realizable. Visualizing a pulmonary artery thrombus in TTE is unusual. It can be identified in the right cardiac chambers in less than 5% of patients with PE. The severity of acute PE is determined by its hemodynamics, the sudden pulmonary hypertension, and the development of obstructive shock. Anticoagulation therapy is the cornerstone of PE management and should be initiated as soon as possible.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report

BackgroundIsolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. Case ReportA 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum β-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. Why Should an Emergency Physician Be Aware of This?Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Abstract 19175: Anaphylaxis After Alteplase During Treatment of Pulmonary Embolism

Introduction: Anaphylaxis is a rare complication to alteplase, a recombinant tissue plasminogen activator (tPA), during administration for pulmonary embolism (PE). Case Presentation: A 72-year-old male with a history of necrotizing fasciitis, recent below the knee amputation, and concern for metastatic melanoma had been undergoing treatment for an acute DVT with apixaban when he presented with an extensive saddle pulmonary embolism. He was evaluated by a Pulmonary Embolism Response Team (PERT) and classified as high risk (sPESI 2, new right ventricular dysfunction, and hypoxemia) and treated with 50 mg alteplase over two hours. At the end of his infusion, he experienced worsening hypoxemia and sudden hypotension treated with fluid resuscitation and an epinephrine infusion. Hemodynamic instability was thought to be secondary to obstructive shock so an additional 50 mg of alteplase was ordered. After the initial bolus of 10 mg alteplase, the patient demonstrated signs of anaphylaxis. He was initially treated with epinephrine, diphenhydramine, famotidine, methylprednisolone, and lactated ringers for the anaphylactic shock. The patient eventually required the addition of norepinephrine, vasopressin, and methylene blue for resolution of the shock. No additional alteplase was administered and a heparin infusion was resumed for treatment of the pulmonary embolism. He was ultimately successfully weaned off vasopressors and oxygen support with resolution of the pulmonary embolism. Discussion: Cardiac critical care providers should monitor for signs of anaphylaxis when using tPA in the management of PE. The main intervention of anaphylactic shock is administration of epinephrine. Updated guidelines recommend use of intramuscular epinephrine in the setting of anaphylaxis.

Abstract 12001: To Bleed or Not to Bleed: The Challenging Management of Saddle Pulmonary Embolism in a Patient With Widely Metastatic Breast Cancer

Introduction: In patients with high-risk pulmonary embolism (PE), anticoagulation (AC) is the mainstay of treatment before and after systemic thrombolysis and/or catheter-directed therapy. Our case highlights a challenging clinical decision where AC had to be initiated due to hemodynamic instability despite its controversial role in patients with CNS metastases. Case Description: A 52 years old female with ER+/PR+/HER2- breast cancer with widespread brain &amp; vertebral metastases presented after a syncopal event. She had tachycardia and hypotension necessitating IV fluids and vasopressors. Echocardiogram showed RV dilation with reduced systolic function &amp; septal wall motion concerning for RV pressure overload. CTA of chest showed large saddle PE with extension into bilateral segmental arteries and enlarged RV. Significant labs: Troponin-I 1.64 ng/mL, BNP 186 pg/mL, hemoglobin 8 g/dL, and platelets 54,000/μl. She was initiated on IV heparin but given worsening hemodynamic instability, she underwent catheter-based thrombectomy with improvement in hemodynamics. Serial CT head showed no evidence of intracranial hemorrhage but she developed diffuse alveolar hemorrhage necessitating intubation. Her bleeding eventually resolved, and she was extubated and discharged on DOAC. Discussion: This patient had high-risk PE given her hemodynamic instability, elevation in cardiac biomarkers, and RV strain on imaging. Treatment includes AC followed by systemic thrombolysis or catheter-directed therapy followed by AC. This patient’s management was complicated due to widespread metastases, thrombocytopenia and anemia. AC was nonetheless initiated due to her hemodynamic instability and patient eventually required thrombectomy. Conclusion: Brain metastases are an absolute contraindication to systemic thrombolysis, but the role of systemic AC is controversial. Our case highlights the importance of personalized decision-making regarding AC.

S3855 A Rare Case of Saddle Pulmonary Embolism Secondary to Hemorrhagic Hepatic Cyst

S3855 A Rare Case of Saddle Pulmonary Embolism Secondary to Hemorrhagic Hepatic Cyst

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

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

Mortality and Outcomes in Cerebrovascular Disease Patients With Emphasis on COVID-19: A Cross-Sectional Analysis of the National Inpatient Sample 2020.

Background COVID-19-related pulmonary complications have been explored extensively in the recent past. There is also a significant amount of literature on the neurological manifestations of COVID-19. However, there exists an unmet need to assess the impact of COVID-19 on patients with cerebrovascular diseases and its role in affecting mortality in such patients. Methods In this cross-sectional study, we analyzed 401,318 hospitalized patients with cerebrovascular diseases using the discharge data from the National Inpatient Sample 2020 to assess the association of COVID-19 with multiple clinical conditions, along with additional factors, such as length of stay in the hospital, total charges incurred, region and type of hospital, and primary insurance/payer in the United States of America. We used a multivariable logistic regression model to predict factors relating to mortality in such patients. Results The mortality during hospitalization in patients with cerebrovascular disease who were also diagnosed with COVID-19 was significantly higher than the patients without COVID-19 (22.50% vs 5.44%, p-value <0.0001). COVID-19 independently increased the odds of death significantly in patients with cerebrovascular diseases (adjusted OR = 4.81, p-value <0.0001). Other statistically and clinically significant factors that contributed to increased odds of mortality in such patients were comorbidities such as moderate/severe liver disease, myocardial infarction, congestive heart failure, and complications such as the development of a saddle pulmonary embolus. Conclusion COVID-19 was associated with higher mortality in patients with cerebrovascular diseases. It also significantly increased the duration of hospital stay and odds of mortality in such patients.

Dispelling the Saddle Pulmonary Embolism Myth (from a Comparison of Saddle Versus Non-Saddle Pulmonary Embolism)

In the setting of an acute pulmonary embolism (PE), there is often an assumed association between a saddle PE (SPE) and increased clinical severity. We aimed to determine the magnitude of SPE proximal pulmonary artery (PA) flow obstruction and its impact on right ventricular (RV) function in the setting of acute PE in a single-center series. From 2005 to 2022, patients with acute PE presenting with acute RV dysfunction requiring intervention were classified as SPE and non-SPE based on presenting computed tomography (CT) scans. SPE flow obstruction was determined by the ratio of the orthogonal cross-sectional surface area measurements of clot and native PA at the location of maximum clot burden in the right PA and left PA. Presenting RV function based on clinical and imaging parameters (CT and transthoracic echocardiography) were compared between SPE and non-SPE cohorts. A total of 174 patients were identified (SPE 92 [52.9%] and non-SPE 82 [47.1%]). Demographics and co-morbidities were similar. In patients with SPE, there was a mean 25.9% total flow obstruction (right PA 26.9% and left PA 25.5%). Non-SPE had greater clinical RV dysfunction on presentation as reflected by more high-risk PE (43.9% vs 26.1%, p=0.01), need for venoarterial extracorporeal membrane oxygenation (21.9% vs 10.9%, p=0.05), and more preoperative cardiopulmonary resuscitation (16.7% vs 7.8%, p=0.08). RV:left ventricular ratio (CT and transthoracic echocardiography) and RV fractional area change were statistically similar between groups. In-hospital mortality was statistically similar between cohorts (4.9% non-SPE vs 2.1% SPE, p=0.32).In conclusion, in a single-center series of patients with acute PE with RV dysfunction, SPE did not cause proximal flow-limiting obstruction. Non-SPE was associated with more clinical RV dysfunction than SPE. Thus, it should not be assumed that a non-SPE is a marker of patient stability.

Saddle pulmonary embolism in the setting of COVID-19 infection: A systematic review of case reports and case series.

Saddle pulmonary embolism (SPE) is a rare type of pulmonary embolism that can lead to hemodynamic compromise causing sudden deaths. Due to a dearth of large prospective studies in this area, little is known regarding the epidemiology, and prognosis and factors affecting the latter for COVID-19-associated SPE. We aimed to describe COVID-19-associated SPE and quantify and compare mortality and factors affecting mortality among the cases. We included a total of 25 publications with a total of 35 cases. The average age was 45 ± 16.3 years with 11 females and 24 males. Dyspnoea (82.5%), orthopnoea (43.5%), and cough (43.5%) were the most common symptoms, and obstructive shock was present in five (21.7%) patients. The average reported oxygen (O2) saturation was 85.8% ± 11.9 mm Hg. Hypertension (26.1%), diabetes (21.7%), and deep vein thrombosis (21.7%) were the most commonly reported comorbidities. Right heart strain was recognized in seven (30%) patients on electroencephalogram (S1QIIITIII) and 12 (52.2%) patients on echocardiogram. Anticoagulation, thrombolysis, and percutaneous intervention were tried in 21 (91.3%), 13 (56.5%), and 6 (26.1%) cases, respectively. Despite the aggressive management, 2 of 25 (8.7%) patients died in our smaller case report cohort. We conclude that despite aggressive management modalities, the mortality of SPE remains high in COVID-19.

Clinical features and risk factors of adverse clinical outcomes in central pulmonary embolism using machine learning analysis

BackgroundIn prior studies, central pulmonary embolism (PE) was associated with high clot burden and was considered an independent predictor for thrombolysis. Further information about predictors of adverse outcomes in these patients is needed for better risk stratification. The objective is to describe independent predictors of adverse clinical outcomes in patients with central PE. MethodsLarge retrospective, observational, and single-center study of hospitalized patients with central PE. Data were gathered on demographics, comorbidities, clinical features on admission, imaging, treatments, and outcomes. Multivariable standard and Least Absolute Shrinkage and Selection Operator (LASSO) machine learning logistic regressions and sensitivity analyses were used to analyze factors associated with a composite of adverse clinical outcomes, including vasopressor use, mechanical ventilation, and inpatient mortality. ResultsA total of 654 patients had central PE. The mean age was 63.1 years, 59% were women, and 82% were African American. The composite adverse outcome was observed in 18% (n = 115) of patients. Serum creatinine elevation (odds ratio [OR] = 1.37, 95% CI = 1.20–1.57; p = 0.0001), white blood cell (WBC) count elevation (OR = 1.10, 95% CI = 1.05–1.15; p < 0.001), higher simplified pulmonary embolism severity index (sPESI) score (OR = 1.47, 95% CI = 1.18–1.84; p = 0.001), serum troponin elevation (OR = 1.26, 95% CI 1.02–1.56; p = 0.03), and respiratory rate increase (OR = 1.03, 95% CI = 1.0–1.05; p = 0.02) were independent predictors of adverse clinical outcomes. ConclusionAmong patients with central PE, higher sPESI score, WBC count elevation, serum creatinine elevation, serum troponin elevation, and respiratory rate increase were independent predictors of adverse clinical outcomes. Right ventricular dysfunction on imaging and saddle PE location did not predict adverse outcomes.

Case Report of Pulmonary Embolism with Right Ventricular Strain in a Young Female

Acute pulmonary embolism (PE) is when one or more thrombus travel to the lungs and obstruct the pulmonary artery or one of the branches of the pulmonary tree, producing signs and symptoms immediately after the obstruction. Saddle pulmonary embolism (SPE) is a rare type of acute PE that can lead to hemodynamic instability and death. The incidence of pulmonary embolism increases with age. In women, the risk of PE increases with pregnancy, hormonal contraceptives, and hormone replacement therapy. In this case, the patient was in her forties and presented with a sudden episode of continuous dyspnea that worsened over four hours. The dyspnea was associated with palpitations and diaphoresis. The clinical scoring tools had a low pre-test probability for PE. The patient had no risk factors for PE other than being obese. Significant laboratory workup showed troponin of 0.10, D-dimer of 8.10, and a B-type natriuretic peptide (BNP) of 1,160. Her computed tomography angiography (CTA) showed extensive pulmonary emboli in the bilateral main and segmental pulmonary arteries, with findings consistent with right heart strain. The patient was managed with an unfractionated heparin loading dose in the ED based on her weight, followed by a heparin drip. Then, the patient was transferred to a tertiary medical center for further interventions. Prompt recognition and treatment of a submassive PE are fundamental to improving patient mortality and morbidity.

Case Series of Patients With Intermediate-High Risk Pulmonary Embolism in the Setting of Trauma Undergoing Mechanical Thrombectomy

In patients with pulmonary embolism (PE) in the setting of trauma, administration of fibrinolytic therapy is contraindicated due to high risk of hemorrhage. Several studies have demonstrated the safety and efficacy of mechanical thrombectomy among all-comers with PE as an alternative to catheter-directed thrombolytics. However, the risks and benefits of mechanical thrombectomy treatment for pulmonary embolism in a trauma population are not well established. A retrospective analysis was performed in all patients who presented to Level 1 Trauma Center with acute trauma who were found to have a pulmonary embolism (PE) treated with mechanical thrombectomy. From May 2019 to December 2020, six patients were identified. Average age was 54 years, and four patients were male. Four patients had a saddle PE on computed tomography. All patients had an intermediate-high risk PE with troponin I elevation >0.04 ng/mL (average 0.42 ng/mL). Pulmonary Embolism Severity Index (PESI) score in all six patients was class III or IV. In all patients, the mechanical thrombectomy was performed with mean-PA pressure changing from average 40.33 to 31.5 mmHg. Average Intensive Care Unit (ICU) length of stay post-procedure was five days with two patients not requiring ICU stay. No patient had post-operative bleeding during their index stay. Average hemoglobin drop after mechanical thrombectomy was 1.33 g/dL. One patient died <30 days post-procedure due to septic shock and another >90 days later (5 months) from cardiac arrest from recurrent PE. The other four patients were still living >90 days post-procedure. No immediate or delayed postoperative complications were identified. Mechanical thrombectomy appears to be a safe and effective treatment for patients with recent trauma who have an intermediate-high risk pulmonary embolism.

Prevalence and Predictors of Cardiogenic Shock in Intermediate-Risk Pulmonary Embolism: Insights From the FLASH Registry

BackgroundPatients with acute pulmonary embolism (PE) and hypotension (high-risk PE) have high mortality. Cardiogenic shock can also occur in nonhypotensive or normotensive patients (intermediate-risk PE) but is less well characterized. ObjectivesThe authors sought to evaluate the prevalence and predictors of normotensive shock in intermediate-risk PE. MethodsIntermediate-risk PE patients in the FLASH (FlowTriever All-Comer Registry for Patient Safety and Hemodynamics) registry undergoing mechanical thrombectomy with the FlowTriever System (Inari Medical) were included. The prevalence of normotensive shock (systolic blood pressure ≥90 mm Hg but cardiac index ≤2.2 L/min/m2) was assessed. A composite shock score consisting of markers of right ventricular function and ischemia (elevated troponin, elevated B-type natriuretic peptide, moderately/severely reduced right ventricular function), central thrombus burden (saddle PE), potential additional embolization (concomitant deep vein thrombosis), and cardiovascular compensation (tachycardia) was prespecified and assessed for its ability to identify normotensive shock patients. ResultsOver one-third of intermediate-risk PE patients in FLASH (131/384, 34.1%) were in normotensive shock. The normotensive shock prevalence was 0% in patients with a composite shock score of 0 and 58.3% in those with a score of 6 (highest score). A score of 6 was a significant predictor of normotensive shock (odds ratio: 5.84; 95% CI: 2.00-17.04). Patients showed significant on-table improvements in hemodynamics post-thrombectomy, including normalization of the cardiac index in 30.5% of normotensive shock patients. Right ventricular size, function, dyspnea, and quality of life significantly improved at the 30-day follow-up. ConclusionsAlthough hemodynamically stable, over one-third of intermediate-risk FLASH patients were in normotensive shock with a depressed cardiac index. A composite shock score effectively further risk stratified these patients. Mechanical thrombectomy improved hemodynamics and functional outcomes at the 30-day follow-up.