Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism (original) (raw)
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International Heart Journal, 2016
Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. 1) Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. 2) Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. 3) Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.
The American Journal of the Medical Sciences, 2011
Introduction: The aim of this study was to assess the effect of thrombolysis versus heparin treatment on echocardiographic parameters and clinical outcome, during hospitalization and within the first 180 days after admission, in patients with first episode of sub massive pulmonary embolism (SPE) and right ventricle dysfunction (RVD). Methods: Consecutive patients (age, 18-75 years) with a first episode of SPE, symptoms onset since no more than 6 hours, normal blood prcssure (> 100 mm Hg), echocardiographic evidence of RVD and positive lung spiral computed tomography were double-blind randomized: I group received lOO mg of alteplase (I O-mg bolus, followed by a 90-mg intravenous infusion over a period of2 hours), while the other group received matching placebo. In addition to aIteplase or placebo, both groups received an unfractionated heparin treatment. Echocardiogram was performed at admission, at 24, 48 and 72 hours, at discharge and at 3 and at 6 months after randomization. Results: Seventy-two patients were included into the study; 37 were assigned to thrombolysis and 35 to placebo. Both groups were well matched with regard to features and clinical presentation. Thrombolysis group showed a significant early improvement of RV function compared with heparin group, and this improvement was observed also during the follow-up (I80 days). The same group also showed significant reduction in clinical events during the hospitalization and follow-up. Conclusions: Our data suggest that, in hemodynamically stable patients with SPE, thrombolysis shows an earliest reduction ofRVD and a more favorable trend in clinical outcome, so, it could merit consideration in SPE.
Prognosis of Pulmonary Embolism with Right Ventricular Dysfunction
Journal of Cardiovascular Diseases & Diagnosis
Background: Mortality rate of pulmonary embolism (PE) at 3 months is over 15% for the high risk presentation and varies from 3% to 15% for the intermediate-risk presentation. Thrombolysis in intermediate-risk PE remains a matter of debate. Methods: We undertook a retrospective study over a 11-year period including patients with high and intermediatehigh-risk PE, hospitalised in a medical ICU in a University hospital, to assess medium and long-term prognosis. Results: Our series involved 145 patients, of whom 63 presented high risk PE and 82 had an intermediate-highrisk PE. Thirty-six patients (24.8%) died in the intensive care unit (ICU) including high-risk PE: 34/63 (53.9%), of whom 25 after inaugural cardiac arrest (CA); intermediate-high-risk PE: 2/82 (2.4%). On multivariate analysis, high blood lactates (OR: 1.88; IC 95% 1.18-3.02, p=0.0083), resuscitated CA (OR: 12.33; IC 95% 1.1-137.4, p=0.041), low subaortic velocity time integral (VTI) (OR: 9.22, IC 0.38-0.81, p=0.0024) were independent factors of in-ICU mortality. Twenty-seven patients died after ICU discharge. Echocardiographic checks were performed in 63 patients, in which 4 (6.3%) presented a chronic thromboembolic pulmonary hypertension (CTPH). Conclusion: High-risk PE still has a high mortality rate in the ICU especially when revealed by a cardiac arrest. High blood lactates, resuscitated CA, and low subaortic VTI were independent predictive factors of mortality. In our retrospective cohort, long-term prognosis was good with only 4 cases of CTPH. The low mortality observed with anticoagulant-only treatment do not encourage thrombolysis for management of intermediate-high-risk PE patients.
Management of Massive and Submassive Pulmonary Embolism
American Journal of Therapeutics, 2013
Purpose of review Although early pulmonary revascularization is the treatment of choice for patients with high-risk (massive) pulmonary embolism, it remains controversial in patients with intermediate-risk (submassive) pulmonary embolism until recently. Recent published data on the management of high-risk and intermediate-risk pulmonary embolism patients will be the main focus of this review. Recent findings The PEITHO trial supports the rationale of risk stratification in normotensive patients with pulmonary embolism. Patients with right ventricular dilation on echocardiography and positive cardiac troponin test have a high intermediate risk of complication and death. Thrombolysis prevents hemodynamic collapse in these patients but with an increased risk of major bleeding particularly in older patients (>75 years). Reduced dose of thrombolysis and catheter-based reperfusion with or without fibrinolysis have shown promising results. Summary Thrombolysis is the treatment of choice for patients with high-risk pulmonary embolism. Surgical embolectomy is recommended in case of absolute contra-indication to thrombolysis. In patients with acute right ventricular dysfunction on cardiac imaging and myocardial injury, thrombolysis should be considered if they are 75 years or less of age and are at low risk of bleeding. Full-dose thrombolysis may be excessively risky in patients over 75 years. In patients with either RV dilation or elevated cardiac biomarker, thrombolysis is not recommended.
CHEST Journal, 2009
Background: No published data have systematically documented pulmonary artery pressure over an intermediate time period after submassive pulmonary embolism (PE). The aim of this work was to document the rate of pulmonary hypertension, as assessed noninvasively by estimated right ventricular systolic pressure (RVSP) of > 40 mm Hg 6 months after the diagnosis of submassive PE. Methods: We enrolled 200 normotensive patients with CT angiography-proven PE and a baseline echocardiogram to estimate RVSP. All patients received therapy with unfractionated heparin initially, but 21 patients later received alteplase in response to circulatory shock or respiratory failure. Patients returned at 6 months for repeat RVSP measurement, and assessments of the New York Heart Association (NYHA) score and 6-min walk distance (6MWD). Results: Six months after receiving a diagnosis, 162 of 180 survivors (90%) returned for follow-up, including 144 patients who had been treated with heparin (heparin-only group) and 18 patients who had been treated with heparin plus alteplase (heparin-plus-alteplase group). Among the heparin-only patients, the RVSP at diagnosis was > 40 mm Hg in 50 of 144 patients (35%; 95% CI, 27% to 43%), compared with 10 of 144 patients at follow-up (7%; 95% CI, 3% to 12%). However, the RVSP at follow-up was higher than the baseline RVSP in 39 of 144 patients (27%; 95% CI, 9% to 35%), and 18 of these 39 patients had a NYHA score of > 3 or exercise intolerance (6MWD, < 330 m). Among heparin-plus-alteplase patients, the RVSP was > 40 mm Hg in 11 of 18 patients at diagnosis (61%; 95% CI, 36% to 83%), compared with 2 of 18 patients at follow-up (11%; 95% CI, 1% to 35%). The RVSP at follow-up was not higher than at the time of diagnosis in any of the heparin-plus-alteplase patients (95% CI, 0% to 18%). Conclusions: Six months after experiencing submassive PE, a significant proportion of patients had echocardiographic and functional evidence of pulmonary hypertension.
Determinants of in-hospital clinical outcome in patients with sub-massive pulmonary embolism
Indian Heart Journal, 2018
Introduction: There is limited data regarding in hospital determinants of clinical deterioration and outcome in sub massive pulmonary embolism (PE). We aimed to evaluate these determinants by comparing biomarkers, CT pulmonary angiogram echocardiography, electrocardiography variables. Methods: 57 patients of sub massive PE diagnosed on CT pulmonary angiogram were included. All patients received UFH on admission and were divided into two groups based on their clinical course. Group 1 comprised of patients who remained stable, group 2 of patients who showed signs of clinical deterioration. Results: There were 34(59.6%) patients in group 1 and 23(40.4%) patients in group 2. No significant difference in age, gender, BMI. 59.37% had sub massive PE, 5.26% had mortality and 40.4% had clinical deterioration. Intravenous UFH infusion given to 59.6%, systemic thrombolysis 22.8%, catheter directed mechanical breakdown 14%, surgical embolectomy in 3.5% patients. S1Q3T3, new onset RBBB, T wave inversion > 1.63 mm, Basal RV size > 40 mm, RV: LV ratio > 1.2, Global RV longitudinal strain <À10.75% and RVSP > 39 mmHg profiled high risk group. Serum BNP and CT pulmonary angiogram derived scores didn't differ significantly although CT findings helped to exclude low risk patients (specificity 88%, sensitivity 95%). Conclusions: Physicians should be aware that patients who have ECG and Echocardiography changes suggestive of right ventricular strain and dysfunction above the cut off values and have documented thrombus in Proximal branches (RPA/LPA) or in distal portion of main pulmonary artery may require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation with heparin to prevent clinical deterioration.
Value of right ventricular dysfunction for prognosis in pulmonary embolism
International Journal of Cardiology, 2008
Background: Acute pulmonary embolism (APE) patients with right ventricular dysfunction (RVD) have a worse prognosis. We assessed RVD, deciding the indexes correlating best with prognosis. Methods: The prospective multi-center study included 520 consecutive APE patients from 41 collaborating hospitals in China, between June 2002 and November 2004. RVD was diagnosed in the presence of at least 2 of the following: right ventricular (RV) dilatation, loss of inspiratory collapse of inferior vena cava (IVC), right ventricular hypokinesis, tricuspid regurgitant jet velocity N 2.8 m/s. Results: Mean age was 57.4 ± 14.1 years and 323 patients (62.1%) were male. The 14-day mortality in normotensive patients with RVD was higher (2.0% vs 0.4%, p b 0.01) than without RVD. RVD was associated with adverse 14-day outcomes (OR 5.23, 95% CI, 2.44-11.23) and the combination of RV dilation and IVC broadening was more valuable than the combination of RV dilation and RV hypokinesis (p b 0.01). A multiple logistic regression model implied that RVD, right/left ventricular end-diastolic diameter ratio (RVED/LVED) and systolic pulmonary artery pressure (SPAP) be independent predictors of adverse 14-day clinical outcomes (p b 0.01). ROC curve showed that the best cut-off values of RVED/LVED and SPAP were 0.67 and 60 mm Hg, respectively. Hemodynamic instability, 14-day clinical outcome, and SPAP were independent harbingers for 3-month outcomes (p b 0.01). Conclusions: RVD was a discriminator for a poor prognosis in normotensive patients. Early detection of RVD (especially combination of RV dilation and IVC broadening, RVED/LVED N 0.67 and/or SPAP N 60 mm Hg) was beneficial for identifying high-risk patients. Hemodynamic instability, 14-day clinical outcomes, and SPAP independently predicted 3-month clinical outcomes.
Catheter-directed ultrasound-accelerated thrombolysis for the treatment of acute pulmonary embolism
Thrombosis Research, 2011
Background: Systemic thrombolysis rapidly improves right ventricular (RV) dysfunction in patients with acute pulmonary embolism (PE) but is associated with major bleeding complications in up to 20%. The efficacy of low-dose, catheter-directed ultrasound-accelerated thrombolysis (USAT) on the reversal of RV dysfunction is unknown. Materials and methods: We performed a retrospective analysis of 24 PE patients (60 ± 16 years) at intermediate (n = 19) or high risk (n = 5) from the East Jefferson General Hospital who were treated with USAT (mean rt-PA dose 33.5 ± 15.5 mg over 19.7 hours) and received multiplanar contrast-enhanced chest computed tomography (CT) scans at baseline and after USAT at 38 ± 14 hours. All CT measurements were performed by an independent core laboratory. Results: The right-to-left ventricular dimension ratio (RV/LV ratio) from reconstructed CT four-chamber views at baseline of 1.33 ± 0.24 was significantly reduced to 1.00 ± 0.13 at follow-up by repeated-measures analysis of variance (p b 0.001). The CT-angiographic pulmonary clot burden as assessed by the modified Miller score was significantly reduced from 17.8 ± 5.3 to 8.7 ± 5.1 (p b 0.001). All patients were discharged alive, and there were no systemic bleeding complications but four major access site bleeding complications requiring transfusion and one suspected recurrent massive PE event. Conclusions: In patients with intermediate and high risk PE, low-dose USAT rapidly reverses right ventricular dilatation and pulmonary clot burden.