Submassive Pulmonary Embolism Research Articles

Catheter-directed Thrombolysis vs Suction Thrombectomy in the Management of Submassive Pulmonary Embolism

Catheter-directed Thrombolysis vs Suction Thrombectomy in the Management of Submassive Pulmonary Embolism

Double bad luck: pulmonary embolism and vaginal bleeding - a case report

BackgroundPulmonary embolism is a common and potentially fatal condition. Exogenous estrogens in contraceptives are associated with an increased risk of venous thrombo-embolism. However, discontinuation of a combined oral contraceptive can lead to severe withdrawal bleeding in an anticoagulated patient.Case presentationWe report a case of a 47-year-old female who presented to the emergency room with a two-day history of worsening shortness of breath and chest pain. Her chronic medication included a combined oral contraceptive pill. Transthoracic echocardiogram showed pulmonary hypertension and right ventricular dilatation. Computerized tomography scan revealed bilateral pulmonary embolism. She received thrombolysis with alteplase and was started on rivaroxaban. Five days after discharge, however, she was readmitted with severe vaginal bleeding.Discussion and conclusionWe describe a case of submassive pulmonary embolism, treated with thrombolysis and anticoagulation, who developed severe vaginal bleeding after stopping the contraceptive pill. This case highlights the importance of detailed menstrual history taking when initiating anticoagulation in women. Discontinuation of oral contraceptives, while important in reducing the risk of recurrent thrombosis, could be postponed until the end of the recommended course of anticoagulation and until a safe alternative form of contraception has been established, if required.

F-29 | Improvement in hospital and ICU lengths-of-stay among patients receiving catheter-based therapy for submassive pulmonary embolism, 2018-2023

F-29 | Improvement in hospital and ICU lengths-of-stay among patients receiving catheter-based therapy for submassive pulmonary embolism, 2018-2023

Shear wave elastography values of thrombus in patients with lower extremity deep vein thrombosis for pulmonary embolism detection: the ROC analysis

Rationale: Thrombosis of the iliac (IV) and femoral veins (FV) is one of the most common causes of pulmonary embolism (PE). Modern ultrasound scanners are equipped with the technology of shear wave elastography, which gives a quantitative assessment of thrombus stiffness by Young's modulus reconstruction. However, the lack of convincing data on the role of thrombus stiffness for clinical manifestations of PE hinders the active use of shear wave elastography to diagnose the risk of embolism.
 Aim: To determine the threshold values of the venous thrombus Young’s modulus for deep venous thrombosis (DVT) of the lower extremities complicated by massive PE and/or PE with acute cor pulmonale (ACP).
 Materials and methods: This was a single center cross-sectional study in 101 patients who were hospitalized with the diagnosis of acute (duration of less than 2 weeks) or subacute (from 2 weeks to 3 months) IV and FV thrombosis. Doppler ultrasound of the lower extremity veins and echocardiography were done in all patients. Forty eight patients with clinical signs of PE had chest computed tomography. The venous thrombus stiffness was assessed by shear wave elastography with the Young's modulus reconstruction. We performed the ROC analysis for mean values of the Young's modulus for proximal segments of IV and FV thrombi in patients with DVT and massive PE and ACP.
 Results: PE was diagnosed in 40.6% (26/64) of the patients hospitalized with acute DVT and in 54.1% (20/37) of those with subacute DVT. Echocardiographic signs of ACP in massive PE were found in 47.4% (9/19) of the patients, in submassive and minor PE in 55.6% (15/27). In DVT complicated with PE, the ROC analysis of the shear wave elastography results gave the following threshold values of the mean Young’s modulus for the proximal thrombus segment: for acute IV thrombosis + PE and ACP, ≤ 16.7 kPa (AUC 0.714, sensitivity 100%, specificity 42.1%), in subacute IV thrombosis + PE and APC, ≤ 23.7 kPa (0.939, 100 and 90.9%, respectively), in acute FV thrombosis + massive PE, ≥ 9.5 kPa (0.706, 100 and 50%, respectively), in subacute FV thrombosis + massive PE, ≥ 24.4 kPa (0.550, 60.0 and 68.8%, respectively).
 Conclusion: Shear wave elastography of deep vein thrombi of the lower extremities makes it possible to identify patients with PE and ACP during acute and subacute IV thrombosis and to determine massive PE in acute FV thrombosis.

Cutting-Edge Techniques and Drugs for the Treatment of Pulmonary Embolism: Current Knowledge and Future Perspectives.

Pulmonary embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and treatment. Recent advances have led to the development of newer techniques and drugs aimed at improving PE management, reducing its associated morbidity and mortality and the complications related to anticoagulation. This review provides an overview of the current knowledge and future perspectives on PE treatment. Anticoagulation represents the first-line treatment of hemodynamically stable PE, direct oral anticoagulants being a safe and effective alternative to traditional anticoagulation: these drugs have a rapid onset of action, predictable pharmacokinetics, and low bleeding risk. Systemic fibrinolysis is suggested in patients with cardiac arrest, refractory hypotension, or shock due to PE. With this narrative review, we aim to assess the state of the art of newer techniques and drugs that could radically improve PE management in the near future: (i) mechanical thrombectomy and pulmonary embolectomy are promising techniques reserved to patients with massive PE and contraindications or failure to systemic thrombolysis; (ii) catheter-directed thrombolysis is a minimally invasive approach that can be suggested for the treatment of massive or submassive PE, but the lack of large, randomized controlled trials represents a limitation to widespread use; (iii) novel pharmacological approaches, by agents inhibiting thrombin-activatable fibrinolysis inhibitor, factor Xia, and the complement cascade, are currently under investigation to improve PE-related outcomes in specific settings.

Risks and Benefits of Device-Assisted Treatment of Pulmonary Embolism

AbstractPulmonary embolism (PE) is a common disease associated with significant morbidity and mortality. Despite the familiarity with this disease, the best treatment remains undefined. Traditionally, treatment of PE has involved a choice of anticoagulation, thrombolysis, or surgery. However, the debate over pharmacologic versus mechanical treatment of acute PE reared up again with the advent of user-friendly mechanical and aspiration thrombectomy technologies. This is especially true for submassive PE, which is an area for potential growth both for understanding the pathophysiology of the disease process and management. Multiple devices are available for treatment of PE. Understanding the risks and benefits of each device is paramount in the complex management of PE.

Differentiating electrocardiographic indications of massive and submassive pulmonary embolism: A cross-sectional study in Southern Iran from 2015 to 2020.

Although using electrocardiogram (ECG) for pulmonary embolism (PE) risk stratification has shown mixed results, it is currently used as supplementary evidence in risk stratification. This cross-sectional study aimed to assess and compare ECG findings of massive and submassive PE versus segmental PE. This cross-sectional study included 250 hospitalized patients with a confirmed diagnosis of acute PE from 2015 to 2020 in Southern Iran. Demographic variables, clinical data, troponin levels, on-admission ECG findings, echocardiography findings, and ECG findings 24 h after receiving anticoagulants or thrombolytics were extracted. Patients diagnosed with submassive or massive PE exhibited significantly higher rates of right axis deviation (p = .010), abnormal ST segment (p < .0001), S1Q3T3 pattern (p < .0001), inverted T wave in leads V1-V3 (p < .0001), inverted T wave in leads V4-V6 (p < .0001), and inverted T wave in leads V1-V6 (p < .0001). In a multivariable model, inverted T wave in leads V1-V3, inverted T wave in leads V4-V6, pulse rate, and positive troponin test were the statistically independent variables for predicting submassive or massive PE. Furthermore, inverted T wave in leads V1-V3 (sensitivity: 85%, specificity: 95%, accuracy: 93%, AUC: 0.902) and troponin levels (sensitivity: 72%, specificity: 86%, accuracy: 83%, AUC: 0.792) demonstrated the best diagnostic test performance for discriminating submassive or massive PE from segmental PE. In addition to clinical rules, ECG can serve as an ancillary tool for assessing more invasive testing and earlier aggressive treatments among patients with PE, as it can provide valuable information for the diagnosis and risk stratification of submassive or massive PE.

Racial Disparities and Other Socioeconomic Predictors of Mortality in Acute Pulmonary Embolism Treatment from the National Inpatient Sample

PurposeTo explore the significance of socioeconomic factors such as race and ethnicity as predictors of mortality in submassive and massive acute pulmonary embolism (PE). Materials and MethodsHospitalizations of patients aged >18 years with acute, nonseptic PE from 2016 to 2019 were identified from the National Inpatient Sample and divided into interventional radiology (IR) (catheter-directed thrombolysis and thrombectomy) and non-IR (tissue plasminogen activator) treatments. Statistical analyses calculated significant odds ratios (ORs) via 95% confidence intervals (CIs). The primary outcome of interest was mortality rate. Comorbidities affecting mortality were examined secondarily. ResultsNon-Hispanic (NH) Black, Hispanic, and Asian/Pacific Islander patients were significantly less likely to undergo an IR procedure for acute, nonseptic PE compared with White patients (NH Black, OR, 0.83 [95% CI, 0.76–0.90], P < .05; Hispanic, 0.78 [0.68–0.89], P = .06; Asian/Pacific Islander, 0.71 [0.51–0.98], P = .72); however, these differences were eliminated when propensity score matching was performed for age, biological sex, and primary insurance type or for primary insurance type alone. NH Black patients were significantly more likely to die than White patients, regardless of undergoing non-IR or IR treatment. Overall risk of death was 41% higher for NH Black patients than for White patients (relative risk, 1.41 [95% CI, 1.24–1.60]; P < .001). ConclusionsNH Black patients have a higher risk of mortality from acute, nonseptic PE than White patients. Independent of race, undergoing IR management for acute, nonseptic PEs was associated with a lower mortality rate. Matching for primary insurance type eliminates differences in mortality between races, suggesting that socioeconomic status may determine outcomes in acute PE.

Physiologically Guided Thrombolysis in Pulmonary Embolism

We describe the case of a 69-year-old woman who presented with submassive pulmonary embolism without overt shock, but with significant signs of right ventricular failure and dyspnea on minimal exertion. She was managed using a point-of-care ultrasound and pulmonary artery pressure-guided approach in order to minimize total thrombolytic dose while nonetheless achieving significant physiological improvement.

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.

Deep vein thrombosis and bilateral submassive pulmonary emboli post‐routine sinus lift: A case report and review of the literature

AbstractVenous thromboembolism (VTE) arising after major oral surgery under general anaesthesia is an exceedingly rare occurrence, and under local anaesthesia even more so. We report a case of a 55‐year‐old male with a remote history of squamous cell carcinoma of the left tonsil, in remission, who developed deep vein thrombosis and bilateral pulmonary emboli after routine sinus lift under local anaesthetic. We discuss the diagnosis, risk factors, and the role of sinus lift in contributing to the onset of VTE in this report. We also discuss a role of potential thromboembolic prophylaxis in high‐risk patients undergoing dentoalveolar procedures under local anaesthetic.

Evaluation of the incremental diagnostic value of the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) in submassive acute pulmonary embolism

Evaluation of the incremental diagnostic value of the echocardiographic Pulmonary to Left Atrial Ratio (ePLAR) in submassive acute pulmonary embolism

Safety and efficacy of clot-dissolving therapies for submassive pulmonary embolism: A network meta-analysis of randomized controlled trials

BackgroundAcute pulmonary embolism (PE) is a serious condition that needs quick and effective treatment. Anticoagulation therapy is the usual care for most PE patients but may not work well for higher-risk ones. Thrombolysis breaks the clot and improves blood flow. It can be given systemically or locally. Ultrasound-assisted catheter-directed thrombolysis (USAT) is a new technique that boosts clot-busting drugs. This network meta-analysis compares death, bleeding, and benefits of four treatments in acute submassive PE. MethodsWe comprehensively searched relevant databases up to July 2023 for RCTs. The outcomes encompassed all-cause mortality, major and minor bleeding, PE recurrence, and hospital stay duration. Bayesian network meta-analysis computed odds ratios (OR) and 95 % CI estimates. ResultsIn this network meta-analysis of 23 RCTs involving 2521 PE patients, we found that SCDT had the most favorable performance for mortality, as it had the lowest odds ratio (OR) among the four interventions (OR 5.41e−42; 95 % CI, 5.68e−97, 1.37e−07). USAT had the worst performance for major bleeding, as it had the highest OR among the four interventions (OR 4.73e+04; 95 % CI, 1.65, 9.16e+13). SCDT also had the best performance for minor bleeding, as it had the lowest OR among the four interventions (OR 5.68e−11; 95 % CI, 4.97e−25, 0.386). ConclusionOur meta-analysis suggests that SCDT is the most effective treatment intervention in improving the risks of All-cause mortality and bleeding. Thrombolytic therapy helps in improving endpoints including the risk of PE recurrence and the duration of hospital stay.

Residual Pulmonary Vascular Obstruction Following Mechanical Thrombectomy for Submassive Pulmonary Embolism: A Single-Center Analysis

BackgroundResidual pulmonary vascular obstruction (RPVO) following pulmonary embolism (PE) is associated with residual dyspnea, recurrent venous thromboembolism, and chronic thromboembolic pulmonary hypertension. Historically, acute PE treated with anticoagulation alone results in high rates of significant RPVO. Contemporary treatment of submassive PE often involves catheter-based interventions, including mechanical thrombectomy (MT), although their relation to RPVO is not characterized. In this study, we aimed to evaluate the rate of ≥10% RPVO in patients treated with MT. MethodsTwenty consecutive patients with submassive PE in a single center underwent MT and subsequent planar ventilation/perfusion scintigraphy scan at a median of 4 months after thrombectomy. A quantitative perfusion score was calculated for each planar ventilation/perfusion scintigraphy study to provide a % perfusion defect. Complete hemodynamic data were collected during the procedure and Miller score was calculated using prepulmonary and postpulmonary angiography. Echocardiographic data were collected prior to, 24 to 48 hours after, and 30 days after the procedure. ResultsFour of 20 patients (20%) had ≥10% RPVO at a median of 4 months follow-up. Following MT, the mean Miller score decreased from 24.5 ± 2.9 to 15.8 ± 3.3 (P < .001) and mean pulmonary artery pressure decreased from 36.1 ± 4.8 mm Hg to 26.8 ± 5.4 mm Hg (P < .001). Right ventricle–to–left ventricle ratio decreased from 1.44 ± 0.2 to 1.05 ± 0.24 by 24 to 48 hours (P < .001) and 0.85 ± 0.1 at 30 days (P < .001) and right ventricular systolic pressure decreased from 63.2 ± 10 mm Hg to 42.1 ± 9.8 mm Hg at 24 to 48 hours (P < .001) and 31.9 ± 10.4 at 30 days (P < .001). ConclusionsIn this prospective study of patients with submassive PE treated with MT, favorable rates of RPVO were noted in comparison to prior studies of anticoagulation alone along with expected acute hemodynamic and echocardiographic improvements. While this study was small in scope, the results suggest the potential for long-term benefits of MT in acute PE in addition to the acute benefits previously described.

A decisive lifesaving tool in submassive pulmonary embolism: Bedside echocardiography

Key Clinical MessageImmediate thrombolysis in submassive pulmonary embolism on the basis of bedside echocardiography can be a lifesaving decision in areas where computed tomography (CT) pulmonary angiogram is not readily available.AbstractBedside echocardiography can be a rapid diagnostic and decision‐making tool for immediate thrombolysis in submassive pulmonary embolism with evidence of progressively failing ventricles. We report a case of submassive pulmonary embolism in a 26‐year‐old male under testosterone replacement therapy, who was successfully thrombolyzed based on bedside echocardiography findings.

Submassive and massive pulmonary embolism. Where do we stand?

Submassive and massive pulmonary embolism. Where do we stand?

Optional therapeutic management of intermediate-risk pulmonary embolism patients

Background: Few studies have evaluated the thrombolytic treatment in patients with intermediate-high risk pulmonary embolism, making this study more valuable. Material and methods: It was a prospective, non-randomized, open-label, single-center study. Eligible patients at the age of 18 or older with an acute pulmonary embolism (PE) confirmed by CT pulmonary angiography with onset until 14 day and signs of right ventricular (RV) overload on echocardiography took part in the study. Pulmonary Arterial CT Obstruction Index Rate (PACTOIR) was used to define the localization and the expansion zone of thromboembolism. This study included 18 patients with intermediate risk and acute submassive pulmonary thromboembolism. In thrombolysis (TT) group (n=9) were used 50 mg of tissue-plasminogen activator (t-PA) administered in infusion as 0.4 mg/h for 2 hours. In the standard anticoagulation group, unfractioned heparin (UFH) was administered as a bolus of 70 units/kg or a maximum of 5000 units, followed by continuous infusion at an initial rate of 16 units/kg or a maximum of 1000 units/h. Results: The mean age for TT group was 69 vs 63 for the UFH group. PACTOIR was 100% in 3 patients in the half-dose rt-PA group and in 2 patients in the UFH group. RV/LV diameter ratio decreased from baseline to 48 h post-procedure (1.55 vs. 1.13; mean difference, -0.42; p &lt; 0.0001). Mean pulmonary artery systolic pressure was 55 mm Hg in both groups (p &lt; 0.05), with 53 [43–60] in TT group vs. 41.5 [37–45] mmHg in UFH group, P&lt;0.05. Also, RV/ LV ratio and systolic PAP decreased significantly in both groups. Severe bleeding with a need in red blood cell transfusion was seen in 0.11% (1 patient) in the TT group vs 0 in UFH group. The hospitalization length of stay was significantly shorter in the TT group (3.8±1.8, p &lt; 0.05). The rate of secondary endpoints was significantly higher in the UFH group with a high rate of pulmonary hypertension (0 vs. 19%, p=0.003). Conclusions: Half-dose thrombolytic therapy in patients diagnosed with submassive pulmonary embolism significantly reduced death and hemodynamic decompensation in the first 7 days compared to anticoagulant therapy only. With all that being said, it can be concluded that patients with high-intermediate risk PE could benefit from reduced-dose TT.

Cardiac leiomyomatosis misdiagnosed initially as submissive pulmonary embolism: a rare case report

This case report presents a rare case of cardiac leiomyomatosis misdiagnosed initially as submassive pulmonary embolism in a 39-year-old woman. The patient presented with syncope and hypotension, leading to an initial diagnosis of submassive pulmonary embolism. However, further investigations revealed a right-sided heart mass on echocardiogram. Surgical intervention was carried out, and the patient’s condition was successfully managed. This case emphasizes the importance of considering rare cardiac tumours in the differential diagnosis of pulmonary embolism.

Diuretics versus volume expansion for acute pulmonary embolism: a systematic review and meta-analysis

Abstract Background/Introduction The potential benefit of diuretics over volume expansion in patients with acute submassive pulmonary embolism with right ventricle dysfunction is controversial. Purpose This study aims to compare the effects of diuretic therapy versus volume expansion in patients hospitalized for pulmonary embolism with right ventricle dysfunction. Methods We performed a systematic review and meta-analysis of studies comparing diuretics and volume expansion for acute submassive pulmonary embolism. PubMed, Embase, and Cochrane databases were searched up to January 20, 2023. Data were extracted from published reports and quality assessment was performed per Cochrane recommendations. Review Manager 5.1 was used for statistical analysis. A random-effects model was used to calculate a pooled effect size and 95% confidence interval. Results Three studies and 176 patients were included. Follow-up ranged from 2 to 30 days. The mean age was 67.5 ± 17.5 years and 52.3% were female. There were no differences between groups regarding the 24h-variation of heart rate (MD -5.98, 95% CI -14.41 to 2.46 beats/min, P = 0.17; Fig. 1A) and systolic blood pressure (MD 9.68, 95% CI -2.94 to 22.30 mmHg, P = 0.13; Fig. 1B). Diuretic therapy was associated with a faster normalisation of BNP (MD -38.38, 95% CI -60.51 to -16.24 hours, P = 0.0007; Fig. 2A). In the 24h-echocardiography parameters, no difference was found in the tricuspid annular plane systolic excursion (TAPSE) (MD -0.15, 95% CI -2.04 to 1.74 mm, P = 0.87; Fig. 2B). Similarly, no significant difference in oxygen requirement, troponin normalization, and inotropic support was seen. Conclusions Compared with the volume expansion strategy, diuretic therapy was not associated with improved hemodynamic and echocardiography parameters at 24h. Prospective and more extensive randomised trials are warranted to confirm the efficacy and safety of diuretics in acute submissive pulmonary embolism with right ventricle dysfunction.

Abstract 13141: Max Opposing Wall Delay in Right Atrial Strain Can Be a Prognostic Factor at 30-day Mortality in Submassive Pulmonary Embolism

Background: Submassive pulmonary embolism (sPE) is common and associated with significant mortality. Right ventricular dyssynchrony caused by sPE were reported previously. However, limited studies have evaluated dyssynchrony of right atrium (RA) strain in the setting of sPE. The purpose of this study was to identify the potential role of RA dyssynchrony in patients with sPE. Methods: 201 patients with sPE were assessed in this retrospective cohort study. All echocardiograms were completed within 48 hours of diagnosis. RA strain was analyzed retroactively using TOMTEC®. RA dyssynchrony was defined as absolute max opposing wall delay which was time interval between peak lateral and septal wall strain in RA after R-R interval correction (maxOWD) (Figure 1). The primary outcome was 30-day all-cause mortality. Results: 201 patients included in the study. Mortality rate of 11.4% was seen at 30 days. Median maxOWD in survivors was significantly low compared to that in non-survivors (4.35 vs 16.20, p &lt; 0.001). Univariable and Multivariable analysis showed maxOWD was an independent factor to predict short-term mortality. Receiver operating characteristics (ROC) analysis revealed area under the curve was 0.795 and best cutoff value was 10.43. Using the cutoff value, Kaplan-Meier curves depicted survival rate in patients with maxOWD &gt; 10.43 was significantly lower than those with maxOWD ≤ 10.43. (Hazard Ratio 7.84, p &lt; 0.001) (Figure 2) Conclusions: Max opposing wall delay after R-R interval correction in RA strain has significant prognostic value in assessing risk of mortality in patients with submassive PE.