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Trends in management and outcomes of pulmonary embolism with a multidisciplinary response team. J Thromb Thrombolysis 2022; 54:449-460. [PMID: 36057054 DOI: 10.1007/s11239-022-02697-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/14/2022] [Indexed: 10/14/2022]
Abstract
Multidisciplinary pulmonary embolism (PE) response teams have garnered widespread adoption given the complexities of managing acute PE and provide a platform for assessment of trends in therapy and outcomes. We describe temporal trends in PE management and outcomes following the deployment of such a team. All consecutive patients managed by our multidisciplinary PE response team activated by the Emergency Department were included over a 5-year calendar period. We examined temporal trends in management and rates of a composite primary endpoint (all-cause-death, major bleeding, recurrent venous thromboembolism, and readmission) at 30 days and 6 months. We assessed 425 patients between 2015 and 2019. We observed an increase in PE acuity and use of systemic thrombolysis. The primary endpoint at 30 days decreased from 16.3% in 2015 to 7.1% in 2019 (adjusted rate ratio per period, 0.63; 95%CI, 0.47-0.84), driven by a decrease in the adjusted rate of major bleeding. Among 406 patients with complete follow-up, the adjusted rate ratio per year for the primary outcome at 6 months was 0.37 (95%CI, 0.19-0.71), driven by a decrease in all-cause mortality. We observed evidence of temporal changes in clinical presentation, therapeutic strategies, and outcomes for acute PE, in parallel to, but not necessarily because of, the implementation of a multidisciplinary response team. Over time, major bleeding, mortality and readmission rates decreased, despite an increase in PE risk category.
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53
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Kerrigan J, Morse M, Haddad E, Willers E, Ramaiah C. Advances in Percutaneous Management of Pulmonary Embolism. Int J Angiol 2022; 31:203-212. [PMID: 36157096 PMCID: PMC9507563 DOI: 10.1055/s-0042-1756174] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.
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Affiliation(s)
- Jimmy Kerrigan
- Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
| | - Michael Morse
- Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
| | - Elias Haddad
- Department of Cardiology, Saint Thomas Health, Nashville, Tennessee
| | - Elisabeth Willers
- Department of Pulmonary Medicine, Saint Thomas Health, Nashville, Tennessee
| | - Chand Ramaiah
- Department of Cardiothoracic Surgery, Saint Thomas Health, Nashville, Tennessee
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54
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Polaková E, Veselka J. Management of Massive Pulmonary Embolism. Int J Angiol 2022; 31:194-197. [PMID: 36157097 PMCID: PMC9507601 DOI: 10.1055/s-0042-1756176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.
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Affiliation(s)
- Eva Polaková
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
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55
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Russell C, Keshavamurthy S. Acute Massive and Submassive Pulmonary Embolism: Historical Considerations/Surgical Techniques of Pulmonary Embolectomy/Novel Applications in Donor Lungs with Pulmonary Emboli. Int J Angiol 2022; 31:188-193. [PMID: 36157100 PMCID: PMC9507568 DOI: 10.1055/s-0042-1756178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolectomy has a chequered history but the quest to surgically treat a patient diagnosed with pulmonary embolism effectively spurred the development of cardiopulmonary bypass and a new dawn for cardiac surgery. The advent of cardiopulmonary bypass, extracorporeal membrane oxygenation, and computed tomography pulmonary angiogram has allowed rapid diagnosis and made surgical pulmonary embolectomy a relatively safe procedure that should be considered when indicated. Pulmonary emboli in donor lungs, often get rejected for transplantation. Ex vivo lung perfusion is among newly available technology with the ability to not only recondition marginal lungs but also treat donor lung pulmonary embolisms, effectively increasing the donor pool.
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Affiliation(s)
- Cody Russell
- The American University of the Caribbean School of Medicine, Pembroke Pines, Florida
| | - Suresh Keshavamurthy
- University of Kentucky College of Medicine, Department of Surgery, Division of Cardiothoracic Surgery, Lexington, Kentucky
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56
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Posa A, Barbieri P, Mazza G, Tanzilli A, Iezzi R, Manfredi R, Colosimo C. Progress in interventional radiology treatment of pulmonary embolism: A brief review. World J Radiol 2022; 14:286-292. [PMID: 36160834 PMCID: PMC9453319 DOI: 10.4329/wjr.v14.i8.286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/14/2022] [Accepted: 08/05/2022] [Indexed: 02/08/2023] Open
Abstract
Pulmonary embolism represents a common life-threatening condition. Prompt identification and treatment of this pathological condition are mandatory. In cases of massive pulmonary embolism and hemodynamic instability or right heart failure, interventional radiology treatment for pulmonary embolism is emerging as an alternative to medical treatment (systemic thrombolysis) and surgical treatment. Interventional radiology techniques include percutaneous endovascular catheter directed therapies as selective thrombolysis and thrombus aspiration, which can prove useful in cases of failure or infeasibility of medical and surgical approaches.
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Affiliation(s)
- Alessandro Posa
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Pierluigi Barbieri
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Giulia Mazza
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Alessandro Tanzilli
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Roberto Iezzi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Riccardo Manfredi
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
| | - Cesare Colosimo
- Department of Diagnostic Imaging, Oncologic Radiotherapy and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Italy
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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58
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Assouline B, Assouline-Reinmann M, Giraud R, Levy D, Saura O, Bendjelid K, Combes A, Schmidt M. Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation? J Clin Med 2022; 11:4734. [PMID: 36012973 PMCID: PMC9409813 DOI: 10.3390/jcm11164734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39-115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.
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Affiliation(s)
- Benjamin Assouline
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Marie Assouline-Reinmann
- Cardiology Department, AP-HP, Sorbonne Université, Pitié-Salpêtrière University Hospital, 75013 Paris, France
| | - Raphaël Giraud
- Intensive Care Unit, Geneva University Hospitals, 1205 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - David Levy
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Ouriel Saura
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, 1205 Geneva, Switzerland
- Faculty of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Alain Combes
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, 75013 Paris, France
| | - Matthieu Schmidt
- Médecine Intensive Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris, 75013 Paris, France
- Sorbonne Université, GRC 30, RESPIRE, UMRS 1166, ICAN Institute of Cardiometabolism and Nutrition, 75013 Paris, France
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59
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Panholzer B, Gravert H, Borzikowsky C, Huenges K, Schoettler J, Schoeneich F, Attmann T, Haneya A, Frank D, Cremer J, Grothusen C. Outcome after surgical embolectomy for acute pulmonary embolism. J Cardiovasc Med (Hagerstown) 2022; 23:519-523. [PMID: 35905002 DOI: 10.2459/jcm.0000000000001349] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Patients with pulmonary embolism (PE) and contraindications for or failed thrombolysis are at the highest risk for PE-related fatal events. These patients may benefit from surgical embolectomy, but data concerning this approach are still limited. METHODS The method used here was retrospective data analysis of 103 patients who underwent surgical embolectomy from 2002 to 2020 at our department. RESULTS Mean age was 58.4 (±15.1) years. Fifty-eight (56.3%) patients had undergone recent surgery; the surgery was tumor associated in 32 (31.1%) cases. Thirty (29.1%) patients had to be resuscitated due to PE, and 13 (12.6%) patients underwent thrombolysis prior to pulmonary embolectomy. Fifteen (14.5%) patients were placed on extra corporeal membrane oxygenation (ECMO) peri-operatively. Five patients (4.9%) died intra-operatively. Neurological symptoms occurred in four patients (3.9%). Thirty-day mortality was 23.3% ( n = 24). Re-thoracotomy due to bleeding was necessary in 12 (11.6%) patients. This parameter was also identified as an independent risk factor for mortality. CONCLUSION Surgical pulmonary embolectomy resulted in survival of the majority of patients with PE and contraindications for or failed thrombolysis. Given the excessive mortality when left untreated, an operative approach should become a routine part of discussions concerning alternative treatment options for these patients.
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Affiliation(s)
- Bernd Panholzer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Hanna Gravert
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Christoph Borzikowsky
- Institute of Medical Informatics and Statistics, Kiel University, University Hospital Schleswig-Holstein
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Jan Schoettler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Felix Schoeneich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Tim Attmann
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Derk Frank
- Department of Internal Medicine III/Cardiology, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany and DZHK, partner site Hamburg, Kiel, Lübeck
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
| | - Christina Grothusen
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel
- Medizinische Klinik I, St. Johannes Hospital Dortmund, Dortmund, Germany
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60
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Rabai F, LaGrew JE, Lazarowicz M, Janelle GM, Goettel N, Caruso LJ. High-Risk Pulmonary Embolism After Hemorrhagic Stroke: Management Considerations During Catheter-Directed Interventional Therapy. J Cardiothorac Vasc Anesth 2022; 36:3645-3654. [DOI: 10.1053/j.jvca.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/17/2022] [Accepted: 04/03/2022] [Indexed: 11/11/2022]
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61
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Tsai HY, Wang YT, Lee WC, Yen HT, Lo CM, Wu CC, Huang KR, Chen YC, Sheu JJ, Chen YY. Efficacy and Safety of Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of High-Risk Pulmonary Embolism: A Retrospective Cohort Study. Front Cardiovasc Med 2022; 9:799488. [PMID: 35310966 PMCID: PMC8924067 DOI: 10.3389/fcvm.2022.799488] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used to treat high-risk pulmonary embolism (PE). However, its efficacy and safety remain uncertain. This retrospective cohort study aimed to determine whether ECMO could improve the clinical outcomes of patients with high-risk PE. Methods Forty patients with high-risk PE, who were admitted to Kaohsiung Chang Gung Memorial Hospital between January 2012 and December 2019, were included in this study. Demographic data and clinical outcomes were compared between patients treated without ECMO (non-ECMO group) and those treated with ECMO (ECMO group). Appropriate statistical tools were used to compare variables between groups and the survival was analyzed using the Kaplan-Meier method. Results The overall in-hospital mortality rate was 55%, in which 65% (26/40) of patients presented with cardiac arrest with a mortality rate of 77%, which was higher than that of patients without cardiac arrest (14%). There was no significant difference in major complications and in-hospital mortality between the non-ECMO and ECMO groups. However, in subgroup analysis, compared with patients treated without ECMO, earlier ECMO treatment was associated with a reduced risk of cardiac arrest (P = 0.023) and lower in-hospital mortality (P = 0.036). A log-rank test showed a significantly higher cumulative overall survival in the earlier ECMO treatment group (P = 0.033). Conclusions In this retrospective cohort study, earlier ECMO treatment was associated with lower in-hospital mortality among unstable patients without cardiac arrest. Our findings suggest that ECMO can be considered as an initial treatment option for patients with high-risk PE in higher-volume hospitals.
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Affiliation(s)
- Hao-Yu Tsai
- Kaohsiung Chang Gung Memorial Hospital Education Department, Kaohsiung, Taiwan
| | - Yu-Tang Wang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yin-Chia Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Ross C, Kumar R, Pelland-Marcotte MC, Mehta S, Kleinman ME, Thiagarajan RR, Ghbeis MB, VanderPluym CJ, Friedman KG, Porras D, Fynn-Thompson F, Goldhaber SZ, Brandão LR. Acute Management of High-Risk and Intermediate-Risk Pulmonary Embolism in Children: A Review. Chest 2022; 161:791-802. [PMID: 34587483 PMCID: PMC8941619 DOI: 10.1016/j.chest.2021.09.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 09/09/2021] [Accepted: 09/20/2021] [Indexed: 10/20/2022] Open
Abstract
Severe forms of pulmonary embolism (PE) in children, althought rare, cause significant morbidity and mortality. We review the pathophysiologic features of severe (high-risk and intermediate-risk) PE and suggest novel pediatric-specific risk stratifications and an acute treatment algorithm to expedite emergent decision-making. We defined pediatric high-risk PE as causing cardiopulmonary arrest, sustained hypotension, or normotension with signs or symptoms of shock. Rapid primary reperfusion should be pursued with either surgical embolectomy or systemic thrombolysis in conjunction with a heparin infusion and supportive care as appropriate. We defined pediatric intermediate-risk PE as a lack of systemic hypotension or compensated shock, but with evidence of right ventricular strain by imaging, myocardial necrosis by elevated cardiac troponin levels, or both. The decision to pursue primary reperfusion in this group is complex and should be reserved for patients with more severe disease; anticoagulation alone also may be appropriate in these patients. If primary reperfusion is pursued, catheter-based therapies may be beneficial. Acute management of severe PE in children may include systemic thrombolysis, surgical embolectomy, catheter-based therapies, or anticoagulation alone and may depend on patient and institutional factors. Pediatric emergency and intensive care physicians should be familiar with the risks and benefits of each therapy to expedite care. PE response teams also may have added benefit in streamlining care during these critical events.
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Affiliation(s)
- Catherine Ross
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Riten Kumar
- Harvard Medical School, Boston, MA,Department of Pediatrics, Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | | | - Shivani Mehta
- Center for Resuscitation Science, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA,College of Osteopathic Medicine, New York Institute of Technology, Old Westbury, NY
| | - Monica E. Kleinman
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Ravi R. Thiagarajan
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Muhammad B. Ghbeis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Christina J. VanderPluym
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Kevin G. Friedman
- Department of Pediatric Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Diego Porras
- Division of Invasive Cardiology, Department of Cardiology, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA,Harvard Medical School, Boston, MA
| | - Samuel Z. Goldhaber
- Harvard Medical School, Boston, MA,Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Leonardo R. Brandão
- Department of Paediatrics, Haematology/Oncology Division, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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63
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Dumantepe M, Ozturk C. Acoustic pulse thrombolysis complemented by ECMO improved survival in patients with high-risk pulmonary embolism. J Card Surg 2022; 37:492-500. [PMID: 35020205 DOI: 10.1111/jocs.16222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal treatment of high-risk pulmonary embolism (PE) with cardiac arrest is still controversial although various treatment approaches have been developed and improved. Here, we present a serie of patients with high-risk PE showing hemodynamic collapse, who were successfully treated with extracorporeal membrane oxygenation (ECMO) as an adjunct to EKOS™ acoustic pulse thrombolysis (APT). METHODS From April 2016 to June 2020, 29 patients with high-risk PE with cardiac arrest were retrospectively included. The mean age was 55.3 ± 9.2 years. A total of 12 (41.3%) patients were female. All patients had cardiac arrest, either as an initial presentation or in-hospital after presentation. All patients exhibited acute symptoms, computed tomography evidence of large thrombus burden, and severe right ventricular dysfunction. Primary outcome was all-cause 30-day mortality. RESULTS Twenty-two patients survived to hospital discharge, with a mean intensive care unit stay of 9.9 ± 1.6 days (range: 7-22 days) and mean length of hospital stay of 23.7 ± 8.5 days (range: 11-44 days). Six patients died from refractory shock. Ninety-day mortality was 24.1% (7/29). The Mean ECMO duration was 3.5 ± 1.1 days and the mean RV/LV ratio decreased from 1.31 ± 0.17 to 0.92 ± 0.11 in patients who survived to discharge. The mean tissue plasminogen activator dose for survivor patients was 20.5 ± 1.6 mg. CONCLUSION Patients with high-risk pulmonary embolism who suffer a cardiac arrest have high morbidity and mortality. APT complemented by ECMO could be a successful treatment option for the patients who have high-risk PE with circulatory collapse.
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Affiliation(s)
- Mert Dumantepe
- Department of Cardiovascular Surgery, Uskudar University School of Medicine, Istanbul, Turkey
| | - Cuneyd Ozturk
- Department of Cardiovascular Surgery, Florence Nightingale Hospital, Istanbul, Turkey
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64
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Shinar Z, Hutin A. Pulmonary ECMO-ism: Let's add PEA to ECPR indications. Resuscitation 2022; 170:293-294. [PMID: 34774708 DOI: 10.1016/j.resuscitation.2021.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Zachary Shinar
- Department of Emergency Medicine, Sharp Memorial Hospital, San Diego, CA, United States.
| | - Alice Hutin
- SAMU de Paris-DAR Necker University Hospital-Assistance Public Hopitaux de Paris, Paris, France
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Stadlbauer A, Philipp A, Blecha S, Lubnow M, Lunz D, Li J, Terrazas A, Schmid C, Lange TJ, Camboni D. Long-term follow-up and quality of life in patients receiving extracorporeal membrane oxygenation for pulmonary embolism and cardiogenic shock. Ann Intensive Care 2021; 11:181. [PMID: 34951692 PMCID: PMC8709804 DOI: 10.1186/s13613-021-00975-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/15/2021] [Indexed: 11/10/2022] Open
Abstract
Background Since 2019, European guidelines recommend considering extracorporeal life support as salvage strategy for the treatment of acute high-risk pulmonary embolism (PE) with circulatory collapse or cardiac arrest. However, data on long-term survival, quality of life (QoL) and cardiopulmonary function after extracorporeal membrane oxygenation (ECMO) are lacking. Methods One hundred and nineteen patients with acute PE and severe cardiogenic shock or in need of mechanical resuscitation (CPR) received venoarterial or venovenous ECMO from 2007 to 2020. Long-term data were obtained from survivors by phone contact and personal interviews. Follow-up included a QoL analysis using the EQ-5D-5L questionnaire, echocardiography, pulmonary function testing and cardiopulmonary exercise testing. Results The majority of patients (n = 80, 67%) were placed on ECMO during or after CPR with returned spontaneous circulation. Overall survival to hospital discharge was 45.4% (54/119). Nine patients died during follow-up. At a median follow-up of 54.5 months (25–73; 56 ± 38 months), 34 patients answered the QoL questionnaire. QoL differed largely and was slightly reduced compared to a German reference population (EQ5D5L index 0.7 ± 0.3 vs. 0.9 ± 0.04; p < 0.01). 25 patients (73.5%) had no mobility limitations, 22 patients (65%) could handle their activities, while anxiety and depression were expressed by 10 patients (29.4%). Return-to-work status was 33.3% (average working hours: 36.2 ± 12.5 h/per week), 15 (45.4%) had retired from work early. 12 patients (35.3%) expressed limited exercise tolerance and dyspnea. 59% (20/34) received echocardiography and pulmonary function testing, 50% (17/34) cardiopulmonary exercise testing. No relevant impairment of right ventricular function and an only slightly reduced mean peak oxygen uptake (76.3% predicted) were noted. Conclusions Survivors from severe intractable PE in cardiogenic shock or even under CPR with ECMO seem to recover well with acceptable QoL and only minor cardiopulmonary limitations in the long term. To underline these results, further research with larger study cohorts must be obtained.
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Affiliation(s)
- Andrea Stadlbauer
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Sebastian Blecha
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Dirk Lunz
- Department of Anesthesiology, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Jing Li
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Armando Terrazas
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Tobias J Lange
- Department of Internal Medicine II, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Daniele Camboni
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
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Radu RI, Ben Gal T, Abdelhamid M, Antohi E, Adamo M, Ambrosy AP, Geavlete O, Lopatin Y, Lyon A, Miro O, Metra M, Parissis J, Collins SP, Anker SD, Chioncel O. Antithrombotic and anticoagulation therapies in cardiogenic shock: a critical review of the published literature. ESC Heart Fail 2021; 8:4717-4736. [PMID: 34664409 PMCID: PMC8712803 DOI: 10.1002/ehf2.13643] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 01/09/2023] Open
Abstract
Cardiogenic shock (CS) is a complex multifactorial clinical syndrome, developing as a continuum, and progressing from the initial insult (underlying cause) to the subsequent occurrence of organ failure and death. There is a large phenotypic variability in CS, as a result of the diverse aetiologies, pathogenetic mechanisms, haemodynamics, and stages of severity. Although early revascularization remains the most important intervention for CS in settings of acute myocardial infarction, the administration of timely and effective antithrombotic therapy is critical to improving outcomes in these patients. In addition, other clinical settings or non-acute myocardial infarction aetiologies, associated with high thrombotic risk, may require specific regimens of short-term or long-term antithrombotic therapy. In CS, altered tissue perfusion, inflammation, and multi-organ dysfunction induce unpredictable alterations to antithrombotic drugs' pharmacokinetics and pharmacodynamics. Other interventions used in the management of CS, such as mechanical circulatory support, renal replacement therapies, or targeted temperature management, influence both thrombotic and bleeding risks and may require specific antithrombotic strategies. In order to optimize safety and efficacy of these therapies in CS, antithrombotic management should be more adapted to CS clinical scenario or specific device, with individualized antithrombotic regimens in terms of type of treatment, dose, and duration. In addition, patients with CS require a close and appropriate monitoring of antithrombotic therapies to safely balance the increased risk of bleeding and thrombosis.
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Affiliation(s)
- Razvan I. Radu
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityCairoEgypt
| | - Elena‐Laura Antohi
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Marianna Adamo
- Cardiothoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
- Division of Research, Kaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Oliviana Geavlete
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
| | - Yuri Lopatin
- Cardiology CentreVolgograd Medical UniversityVolgogradRussian Federation
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Marco Metra
- Cardiology, Cardiothoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - John Parissis
- Second Department of Cardiology, Attikon University HospitalNational and Kapodistrian University of AthensAthensGreece
| | - Sean P. Collins
- Department of Emergency Medicine; Vanderbilt University Medical CentreNashvilleTNUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- ICCU DepartmentEmergency Institute for Cardiovascular Diseases ‘Prof. Dr. C.C. Iliescu’BucharestRomania
- University for Medicine and Pharmacy ‘Carol Davila’ BucharestBucharestRomania
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Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP, Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism. Resuscitation 2021; 170:285-292. [PMID: 34653550 DOI: 10.1016/j.resuscitation.2021.10.007] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 02/02/2023]
Abstract
AIM OF THE STUDY Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE. METHODS We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018. RESULTS At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41-0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43-0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57-0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99-1.01], p = 0.116). CONCLUSION Our findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Department of Angiology, University Hospital Zurich, Switzerland
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Johannes Wild
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Medical Clinic VII, University Hospital Heidelberg, Germany
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Can VA-ECMO Be Used as an Adequate Treatment in Massive Pulmonary Embolism? J Clin Med 2021; 10:jcm10153376. [PMID: 34362159 PMCID: PMC8348430 DOI: 10.3390/jcm10153376] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 12/12/2022] Open
Abstract
Introduction: Massive acute pulmonary embolism (MAPE) with obstructive cardiogenic shock is associated with a mortality rate of more than 50%. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been increasingly used in refractory cardiogenic shock with very good results. In MAPE, although it is currently recommended as part of initial resuscitation, it is not yet considered a stand-alone therapy. Material and Methods: All patients with MAPE requiring the establishment of VA-ECMO and admitted to our tertiary intensive care unit were analysed over a period of 10 years. The characteristics of these patients, before, during and after ECMO were extracted and analysed. Results: A total of 36 patients were included in the present retrospective study. Overall survival was 64%. In the majority of cases, the haemodynamic and respiratory status of the patient improved significantly within the first 24 h on ECMO. The 30-day survival significantly increased when ECMO was used as stand-alone therapy (odds ratio (OR) 15.58, 95% confidence interval (CI) 2.65–91.57, p = 0.002). Nevertheless, when ECMO was implanted following the failure of thrombolysis, the bleeding complications were major (17 (100%) vs. 1 (5.3%) patients, p < 0.001) and the 30-day mortality increased significantly (OR 0.11, 95% CI 0.022–0.520, p = 0.006). Conclusions: The present retrospective study is certainly one of the most important in terms of the number of patients with MAPE and shock treated with VA-ECMO. This short-term mechanical circulatory support, used as a stand-alone therapy in MAPE, allows for the optimal stabilisation of patients.
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Kaso ER, Pan JA, Salerno M, Kadl A, Aldridge C, Haskal ZJ, Kennedy JLW, Mazimba S, Mihalek AD, Teman NR, Giri J, Aronow HD, Sharma AM. Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism: a Meta-Analysis and Call to Action. J Cardiovasc Transl Res 2021; 15:258-267. [PMID: 34282541 PMCID: PMC8288068 DOI: 10.1007/s12265-021-10158-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/09/2021] [Indexed: 01/08/2023]
Abstract
Venoarterial extracorporeal membrane oxygenation (ECMO) has been used to treat acute massive pulmonary embolism (PE) patients. However, the incremental benefit of ECMO to standard therapy remains unclear. Our meta-analysis objective is to compare in-hospital mortality in patients treated for acute massive PE with and without ECMO. The National Library of Medicine MEDLINE (USA), Web of Science, and PubMed databases from inception through October 2020 were searched. Screening identified 1002 published articles. Eleven eligible studies were identified, and 791 patients with acute massive PE were included, of whom 270 received ECMO and 521 did not. In-hospital mortality was not significantly different between patients treated with vs. without ECMO (OR = 1.24 [95% CI, 0.63–2.44], p = 0.54). However, these findings were limited by significant study heterogeneity. Additional research will be needed to clarify the role of ECMO in massive PE treatment.
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Affiliation(s)
- Elona Rrapo Kaso
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Jonathan A Pan
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Michael Salerno
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.,Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA.,Department of Biomedical Engineering, University of Virginia, Charlottesville, VA, USA
| | - Alexandra Kadl
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Chad Aldridge
- Department of Therapy Services, University of Virginia, Charlottesville, VA, USA
| | - Ziv J Haskal
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | - Jamie L W Kennedy
- Division of Cardiology, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | - Sula Mazimba
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA
| | - Andrew D Mihalek
- Department of Medicine, Division of Pulmonary and Critical Care, University of Virginia, Charlottesville, VA, USA
| | - Nicholas R Teman
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, VA, USA
| | - Jay Giri
- Division of Cardiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Herbert D Aronow
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Aditya M Sharma
- Department of Medicine, Cardiovascular Division, University of Virginia, 1215 Lee Street, Charlottesville, VA, USA.
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Tsangaris A, Alexy T, Kalra R, Kosmopoulos M, Elliott A, Bartos JA, Yannopoulos D. Overview of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) Support for the Management of Cardiogenic Shock. Front Cardiovasc Med 2021; 8:686558. [PMID: 34307500 PMCID: PMC8292640 DOI: 10.3389/fcvm.2021.686558] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/11/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiogenic shock accounts for ~100,000 annual hospital admissions in the United States. Despite improvements in medical management strategies, in-hospital mortality remains unacceptably high. Multiple mechanical circulatory support devices have been developed with the aim to provide hemodynamic support and to improve outcomes in this population. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is the most advanced temporary life support system that is unique in that it provides immediate and complete hemodynamic support as well as concomitant gas exchange. In this review, we discuss the fundamental concepts and hemodynamic aspects of VA-ECMO support in patients with cardiogenic shock of various etiologies. In addition, we review the common indications, contraindications and complications associated with VA-ECMO use.
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Affiliation(s)
- Adamantios Tsangaris
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Rajat Kalra
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Marinos Kosmopoulos
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Andrea Elliott
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jason A. Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Demetris Yannopoulos
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, United States
- Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, United States
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71
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Blondon M, Martinez de Tejada B, Glauser F, Righini M, Robert-Ebadi H. Management of high-risk pulmonary embolism in pregnancy. Thromb Res 2021; 204:57-65. [PMID: 34146979 DOI: 10.1016/j.thromres.2021.05.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 05/29/2021] [Indexed: 12/30/2022]
Abstract
Pregnancy-associated high-risk pulmonary embolism (PE) is among the most frequent causes of maternal mortality in the Western world, by causing hemodynamic instability and circulatory failure through a large thrombotic pulmonary obstruction. The very challenging management of these dramatic situations comprises the need to quickly select a therapy of pulmonary reperfusion or hemodynamic replacement, while taking into account both maternal and fetal risks. In this review, we discuss the role of risk stratification in pregnancy-associated PE and the available evidence to support the use of thrombolysis, catheter-directed thrombectomy/thrombolysis, surgical embolectomy and extracorporeal membrane oxygenation. Despite the lack of comparative studies and solid evidence, most reported cases of high-risk pregnancy-associated PE have been treated with thrombolysis, with high maternal and fetal survivals, and thrombolysis is suggested by guidelines in life-threatening PE. For women in the peripartum and early post-partum period, non-fibrinolytic treatments may be preferred as a first-line treatment, if available, because of the particularly high bleeding risk. In all cases, pregnancy-associated high-risk PE requires a multidisciplinary approach involving PE response teams and obstetricians.
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Affiliation(s)
- Marc Blondon
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.
| | | | - Frederic Glauser
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Helia Robert-Ebadi
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Qiu C, Li T, Wei G, Xu J, Yu W, Wu Z, Li D, He Y, Chen T, Zhang J, He X, Hu J, Fang J, Zhang H. Hemorrhage and venous thromboembolism in critically ill patients with COVID-19. SAGE Open Med 2021; 9:20503121211020167. [PMID: 34104439 PMCID: PMC8170290 DOI: 10.1177/20503121211020167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 05/03/2021] [Indexed: 12/28/2022] Open
Abstract
Objective: The majority of patients with COVID-19 showed mild symptoms. However,
approximately 5% of them were critically ill and require intensive care unit
admission for advanced life supports. Patients in the intensive care unit
were high risk for venous thromboembolism and hemorrhage due to the
immobility and anticoagulants used during advanced life supports. The aim of
the study was to report the incidence and treatments of the two
complications in such patients. Method: Patients with COVID-19 (Group 1) and patients with community-acquired
pneumonia (Group 2) that required intensive care unit admission were
enrolled in this retrospective study. Their demographics, laboratory
results, ultrasound findings and complications such as venous
thromboembolism and hemorrhage were collected and compared. Results: Thirty-four patients with COVID-19 and 51 patients with community-acquired
pneumonia were included. The mean ages were 66 and 63 years in Groups 1 and
2, respectively. Venous thromboembolism was detected in 6 (18%) patients
with COVID-19 and 18 (35%) patients with community-acquired pneumonia
(P = 0.09). The major type was distal deep venous thrombosis. Twenty-one
bleeding events occurred in 12 (35%) patients with COVID-19 and 5 bleeding
events occurred in 5 (10%) patients with community-acquired pneumonia,
respectively (P = 0.01). Gastrointestinal system was the most common source
of bleeding. With the exception of one death due to intracranial bleeding,
blood transfusion with or without surgical/endoscopic treatments was able to
manage the bleeding in the remaining patients. Multivariable logistic
regression showed increasing odds of hemorrhage with extracorporeal membrane
oxygenation (odds ratio: 13.9, 95% confidence interval: 4.0–48.1) and
COVID-19 (odds ratio: 4.7, 95% confidence interval: 1.2–17.9). Conclusion: Venous thromboembolism and hemorrhage were common in both groups. The
predominant type of venous thromboembolism was distal deep venous
thrombosis, which presented a low risk of progression. COVID-19 and
extracorporeal membrane oxygenation were risk factors for hemorrhage. Blood
transfusion with or without surgical/endoscopic treatments was able to
manage it in most cases.
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Affiliation(s)
- Chenyang Qiu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tong Li
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Guoqing Wei
- Department of Hematology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jun Xu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Wenqiao Yu
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Ziheng Wu
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Donglin Li
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Yangyan He
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tianchi Chen
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jingchen Zhang
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Xujian He
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Jia Hu
- Department of Emergency, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Junjun Fang
- Intensive Care Unit, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Hongkun Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
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Current Management of Acute Pulmonary Embolism. CURRENT SURGERY REPORTS 2021. [DOI: 10.1007/s40137-021-00293-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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74
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Lüsebrink E, Orban M, Kupka D, Scherer C, Hagl C, Zimmer S, Luedike P, Thiele H, Westermann D, Massberg S, Schäfer A, Orban M. Prevention and treatment of pulmonary congestion in patients undergoing venoarterial extracorporeal membrane oxygenation for cardiogenic shock. Eur Heart J 2021; 41:3753-3761. [PMID: 33099278 DOI: 10.1093/eurheartj/ehaa547] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 04/07/2020] [Accepted: 06/15/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiogenic shock is still a major driver of mortality on intensive care units and complicates ∼10% of acute coronary syndromes with contemporary mortality rates up to 50%. In the meantime, percutaneous circulatory support devices, in particular venoarterial extracorporeal membrane oxygenation (VA-ECMO), have emerged as an established salvage intervention for patients in cardiogenic shock. Venoarterial extracorporeal membrane oxygenation provides temporary circulatory support until other treatments are effective and enables recovery or serves as a bridge to ventricular assist devices, heart transplantation, or decision-making. In this critical care perspective, we provide a concise overview of VA-ECMO utilization in cardiogenic shock, considering rationale, critical care management, as well as weaning aspects. We supplement previous literature by focusing on therapeutic issues related to the vicious circle of retrograde aortic VA-ECMO flow, increased left ventricular (LV) afterload, insufficient LV unloading, and severe pulmonary congestion limiting prognosis in a relevant proportion of patients receiving VA-ECMO treatment. We will outline different modifications in percutaneous mechanical circulatory support to meet this challenge. Besides a strategy of running ECMO at lowest possible flow rates, novel therapeutic options including the combination of VA-ECMO with percutaneous microaxial pumps or implementation of a venoarteriovenous-ECMO configuration based on an additional venous cannula supplying towards pulmonary circulation are most promising among LV unloading and venting strategies. The latter may even combine the advantages of venovenous and venoarterial ECMO therapy, providing potent respiratory and circulatory support at the same time. However, whether VA-ECMO can reduce mortality has to be evaluated in the urgently needed, ongoing prospective randomized studies EURO-SHOCK (NCT03813134), ANCHOR (NCT04184635), and ECLS-SHOCK (NCT03637205). These studies will provide the opportunity to investigate indication, mode, and effect of LV unloading in dedicated sub-analyses. In future, the Heart Teams should aim at conducting a dedicated randomized trial comparing VA-ECMO support with vs. without LV unloading strategies in patients with cardiogenic shock.
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Affiliation(s)
- Enzo Lüsebrink
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Mathias Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Danny Kupka
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Clemens Scherer
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Christian Hagl
- Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Sebastian Zimmer
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Bonn, Sigmund-Freud-Straße 25, 53127 Bonn, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45122 Essen, Germany
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Department of Internal Medicine/Cardiology, Leipzig Heart Institute, Strümpellstraße 39, 04289 Leipzig, Germany
| | - Dirk Westermann
- Klinik für Allgemeine und Interventionelle Kardiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20251 Hamburg, Germany
| | - Steffen Massberg
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
| | - Andreas Schäfer
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Martin Orban
- Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany.,DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377 Munich, Germany
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Singh M, Shafi I, Rali P, Panaro J, Lakhter V, Bashir R. Contemporary Catheter-Based Treatment Options for Management of Acute Pulmonary Embolism. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2021; 23:44. [PMID: 33994774 PMCID: PMC8113788 DOI: 10.1007/s11936-021-00920-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2021] [Indexed: 01/21/2023]
Abstract
Introduction Acute pulmonary embolism (PE) remains an important cause of cardiovascular mortality and morbidity in the USA and worldwide. Catheter-based therapies are emerging as a new armamentarium for improving outcomes in these patients. Purpose of review The purpose of this review is to familiarize the clinicians with (1) various types of catheter-based modalities available for patients with acute PE, (2) advantages, disadvantages, and appropriate patient selection for the use of these devices, and (3) evidence base and the relevance of such therapies in the COVID-19 pandemic. Recent findings There are four main types of catheter-based therapies in acute PE: (1) standard catheter-directed thrombolysis (CDT), (2) ultrasound-assisted CDT, (3) pharmacomechanical CDT, and (4) mechanical thrombectomy without thrombolysis. Ultrasound-assisted thrombolysis is the most widely studied modality in this group; however, evidence base for other catheter-based technologies is rapidly emerging. Summary Current use of catheter-based therapies is most suitable for patients with intermediate and high-risk acute PE. The adoption of a multidisciplinary approach like the pulmonary embolism response team (PERT) is desirable for appropriate patient selection and possibly/potentially improving patient outcomes. We discuss the current status of these therapies.
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Affiliation(s)
- Maninder Singh
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Irfan Shafi
- Department of Internal Medicine, Wayne State University/DMC, Detroit, MI USA
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA USA
| | - Joseph Panaro
- Department of Radiology, Temple University Hospital, Philadelphia, PA USA
| | - Vladimir Lakhter
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA
| | - Riyaz Bashir
- Department of Cardiovascular Disease, Temple University Hospital, Philadelphia, PA USA.,Division of Cardiovascular Diseases, Temple University Hospital, 3401 N. Broad Street (9PP), Philadelphia, PA 19140 USA
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76
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Tran D, Hays N, Shah A, Pasrija C, Cires-Drouet RS, Toursavadkohi SA, Mazzeffi MA, Herr DL, Madathil RJ, Gammie JS, Griffith BP, Deatrick KB, Kaczorowski DJ. Ultrasound-assisted catheter directed thrombolysis for pulmonary embolus during extracorporeal membrane oxygenation. J Card Surg 2021; 36:2685-2691. [PMID: 33982349 DOI: 10.1111/jocs.15622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/29/2021] [Accepted: 04/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute pulmonary embolism (PE) is the third most common cause of cardiovascular death. For patients who are hemodynamically unstable, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support has been shown to provide hemodynamic stability, and allow time for definitive treatment and recovery. Ultrasound-assisted catheter directed thrombolysis (USAT) has the potential to be a safe adjunct and expedite right ventricular (RV) recovery for patients requiring VA-ECMO for PE. METHODS A review of all VA-ECMO patients from January 2017 to September 2019 was performed. A total of 49 of these patients were cannulated due to a PE. USAT therapy was used as an adjunct in 6 (12%) of these patients. These 6 patients were given standardized USAT therapy with EKOs catheters at 1 mg/h of tissue plasminogen activator with an unfractionated heparin infusion for additional systemic anticoagulation. Outcomes, including in-hospital death, 90-day survival, RV recovery, and complications, were examined in the cohort of patients that received USAT as an adjunct to ECMO. RESULTS Median age was 54 years old. Five of the six patients presented with a massive PE and had a PE severity score of Class V. One patient presented with a submassive PE with a Bova score of 2, but was cannulated to VA-ECMO in the setting of worsening RV function. All patients demonstrated recovery of RV function, were free from in-hospital death, and were alive at 90-day follow-up. CONCLUSION Ekosonic endovascular system therapy may be a safe and feasible adjunct for patients on VA-ECMO for PE, and allow for survival with RV recovery with minimal complications.
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Affiliation(s)
- Douglas Tran
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nicole Hays
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Aakash Shah
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Chetan Pasrija
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Rafael S Cires-Drouet
- Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Shahab A Toursavadkohi
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michael A Mazzeffi
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Daniel L Herr
- Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Ronson J Madathil
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - James S Gammie
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Bartley P Griffith
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - David J Kaczorowski
- Division of Cardiac Surgery, University of Maryland Medical Center, Baltimore, Maryland, USA
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Prasad NK, Boyajian G, Tran D, Shah A, Jones KM, Madathil RJ, Deatrick KB, Cires-Drouet R, Kaczorowski DJ. Veno-Arterial Extracorporeal Membrane Oxygenation for Pulmonary Embolism after Systemic Thrombolysis. Semin Thorac Cardiovasc Surg 2021; 34:549-557. [PMID: 33974966 DOI: 10.1053/j.semtcvs.2021.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/06/2021] [Indexed: 02/06/2023]
Abstract
Massive pulmonary embolism (PE) is a life-threatening condition with a high mortality. Both systemic thrombolytics and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been used in the management of massive PE. However, the safety of VA- ECMO in the setting of recent thrombolytic administration is not clear. The purpose of this study is to analyze the outcomes of patients who received VA-ECMO in the setting of systemic thrombolytics (ST). A single institution retrospective study of PE patients treated with VA-ECMO between December 2015 and December 2020 was performed. Patients who received ST were compared with those who did not receive ST. Outcomes, including mortality, major bleeding, duration of mechanical ventilation, need for renal replacement therapy, and length of hospital stay, were compared. A total of 83 patients with PE required VA-ECMO support and 18 of these received systemic thrombolytics. There was no statistically significant difference in survival to discharge between the patients who received ST compared with those who did not (88.9% vs 84.6%; p = 0.94). Major bleeding events occurred more often in patients who received ST (61.1% vs 26.2%; p = 0.01). There was no significant difference in time on mechanical ventilation, need for renal replacement therapy, or length of stay between the groups. Reasonable survival can be achieved despite an increased frequency of major bleeding events in patients that receive ST prior to VA-ECMO for PE. ST administration should not be considered an absolute contraindication to VA-ECMO. Further multi-center studies are needed to corroborate these findings.
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Affiliation(s)
- Nikhil K Prasad
- Division of General Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Gregory Boyajian
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Douglas Tran
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aakash Shah
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Kevin M Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland; R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, Maryland
| | - Ronson J Madathil
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - K Barry Deatrick
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Rafael Cires-Drouet
- Division of Vascular Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - David J Kaczorowski
- Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland.
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78
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Advanced therapies for pulmonary embolism. Curr Opin Pulm Med 2021; 26:397-405. [PMID: 32740381 DOI: 10.1097/mcp.0000000000000714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Treatment options for managing patients with acute pulmonary embolism are rapidly evolving. In this review, we discuss the supporting evidence and implementation strategies for these advanced therapeutic modalities. RECENT FINDINGS We review the recent data supporting systemic and catheter directed thrombolytic therapies, mechanical embolectomy, use of extracorporeal membrane oxygen support, and pulmonary embolism response teams in managing patients with acute pulmonary embolism. We discuss the major professional society recommendations regarding their implementation. SUMMARY A review of advanced therapies for pulmonary embolism.
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79
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A New Lease on Life. Crit Care Med 2021; 49:863-865. [PMID: 33854011 DOI: 10.1097/ccm.0000000000004881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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80
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Rousseau H, Del Giudice C, Sanchez O, Ferrari E, Sapoval M, Marek P, Delmas C, Zadro C, Revel-Mouroz P. Endovascular therapies for pulmonary embolism. Heliyon 2021; 7:e06574. [PMID: 33889762 PMCID: PMC8047492 DOI: 10.1016/j.heliyon.2021.e06574] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 11/18/2020] [Accepted: 03/17/2021] [Indexed: 12/13/2022] Open
Abstract
Purpose The aim of this article is to define the place of new endovascular methods for the management of pulmonary embolisms (PE), on the basis of a multidisciplinary consensus. Method and results Briefly, from the recent literature, for high-risk PE presenting with shock or cardiac arrest, systemic thrombolysis or embolectomy is recommended, while for lowrisk PE, anticoagulation alone is proposed. Normo-tense patients with PE but with biological or imaging signs of right heart dysfunction constitute a group known as “at intermediate risk” for which the therapeutic strategy remains controversial. In fact, some patients may require more aggressive treatment in addition to the anticoagulant treatment, because approximately 10% will decompensate hemodynamically with a high risk of mortality. Systemic thrombolysis may be an option, but with hemorrhagic risks, particularly intra cranial. Various hybrid pharmacomechanical approaches are proposed to maintain the benefits of thrombolysis while reducing its risks, but the overall clinical experience of these different techniques remains limited. Patients with high intermediate and high risk pulmonary embolism should be managed by a multidisciplinary team combining the skills of cardiologists, resuscitators, pneumologists, interventional radiologists and cardiac surgeons. Such a team can determine which intervention – thrombolysis alone or assisted, percutaneous mechanical fragmentation of the thrombus or surgical embolectomy – is best suited to a particular patient. Conclusions This consensus document define the place of endovascular thrombectomy based on an appropriate risk stratification of PE.
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Affiliation(s)
| | | | - Olivier Sanchez
- Service de Pneumologie et soins intensifs HEGP Paris, France
| | | | - Marc Sapoval
- Service de Radiologie interventionnelle HEGP Paris, France
| | - Pierre Marek
- Service d'imagerie CHU Toulouse, Rangueil, France
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81
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Karami M, Mandigers L, Miranda DDR, Rietdijk WJR, Binnekade JM, Knijn DCM, Lagrand WK, den Uil CA, Henriques JPS, Vlaar APJ. Survival of patients with acute pulmonary embolism treated with venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis. J Crit Care 2021; 64:245-254. [PMID: 34049258 DOI: 10.1016/j.jcrc.2021.03.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/21/2020] [Accepted: 03/14/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND To examine whether venoarterial extracorporeal membrane oxygenation (VA-ECMO) improves survival of patients with acute pulmonary embolism (PE). METHODS Following the PRISMA guidelines, a systematic search was conducted up to August 2019 of the databases: PubMed/MEDLINE, EMBASE and Cochrane. All studies reporting the survival of adult patients with acute PE treated with VA-ECMO and including four patients or more were included. Exclusion criteria were: correspondences, reviews and studies in absence of a full text, written in other languages than English or Dutch, or dating before 1980. Short-term (hospital or 30-day) survival data were pooled and presented with relative risks (RR) and 95% confidence intervals (95% CI). Also, the following pre-defined factors were evaluated for their association with survival in VA-ECMO treated patients: age > 60 years, male sex, pre-ECMO cardiac arrest, surgical embolectomy, catheter directed therapy, systemic thrombolysis, and VA-ECMO as single therapy. RESULTS A total of 29 observational studies were included (N = 1947 patients: VA-ECMO N = 1138 and control N = 809). There was no difference in short-term survival between VA-ECMO treated patients and control patients (RR 0.91, 95% CI 0.71-1.16). In acute PE patients undergoing VA-ECMO, age > 60 years was associated with lower survival (RR 0.72, 95% CI 0.52-0.99), surgical embolectomy was associated with higher survival (RR 1.96, 95% CI 1.39-2.76) and pre-ECMO cardiac arrest showed a trend toward lower survival (RR 0.88, 95% CI 0.77-1.01). The other evaluated factors were not associated with a difference in survival. CONCLUSIONS At present, there is insufficient evidence that VA-ECMO treatment improves short-term survival of acute PE patients. Low quality evidence suggest that VA-ECMO patients aged ≤60 years or who received SE have higher survival rates. Considering the limited evidence derived from the present data, this study emphasizes the need for prospective studies. PROTOCOL REGISTRATION PROSPERO CRD42019120370.
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Affiliation(s)
- Mina Karami
- Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Loes Mandigers
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Wim J R Rietdijk
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jan M Binnekade
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Daniëlle C M Knijn
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Corstiaan A den Uil
- Department of Intensive Care Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - José P S Henriques
- Heart Center; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, Huisman MV, Humbert M, Jennings CS, Jiménez D, Kucher N, Lang IM, Lankeit M, Lorusso R, Mazzolai L, Meneveau N, Ní Áinle F, Prandoni P, Pruszczyk P, Righini M, Torbicki A, Van Belle E, Zamorano JL. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 2021; 41:543-603. [PMID: 31504429 DOI: 10.1093/eurheartj/ehz405] [Citation(s) in RCA: 2146] [Impact Index Per Article: 715.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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83
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Luc JGY, Färber G, Myers PO. Highlights from the 34th Annual Meeting of the European Association for Cardio-Thoracic Surgery. Artif Organs 2021; 45:E26-E37. [PMID: 33616275 DOI: 10.1111/aor.13908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 01/04/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Jessica G Y Luc
- Division of Cardiovascular Surgery, Department of Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Patrick O Myers
- Division of Cardiac Surgery, CHUV-Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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84
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ECMO in Cardiac Arrest: A Narrative Review of the Literature. J Clin Med 2021; 10:jcm10030534. [PMID: 33540537 PMCID: PMC7867121 DOI: 10.3390/jcm10030534] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/12/2021] [Accepted: 01/26/2021] [Indexed: 01/07/2023] Open
Abstract
Cardiac arrest (CA) is a frequent cause of death and a major public health issue. To date, conventional cardiopulmonary resuscitation (CPR) is the only efficient method of resuscitation available that positively impacts prognosis. Extracorporeal membrane oxygenation (ECMO) is a complex and costly technique that requires technical expertise. It is not considered standard of care in all hospitals and should be applied only in high-volume facilities. ECMO combined with CPR is known as ECPR (extracorporeal cardiopulmonary resuscitation) and permits hemodynamic and respiratory stabilization of patients with CA refractory to conventional CPR. This technique allows the parallel treatment of the underlying etiology of CA while maintaining organ perfusion. However, current evidence does not support the routine use of ECPR in all patients with refractory CA. Therefore, an appropriate selection of patients who may benefit from this procedure is key. Reducing the duration of low blood flow by means of performing high-quality CPR and promoting access to ECPR, may improve the survival rate of the patients presenting with refractory CA. Indeed, patients who benefit from ECPR seem to carry better neurological outcomes. The aim of this present narrative review is to present the most recent literature available on ECPR and to clarify its potential therapeutic role, as well as to provide an in-depth explanation of equipment and its set up, the patient selection process, and the patient management post-ECPR.
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Baldetti L, Beneduce A, Cianfanelli L, Falasconi G, Pannone L, Moroni F, Venuti A, Sacchi S, Gramegna M, Pazzanese V, Calvo F, Gallone G, Pagnesi M, Cappelletti AM. Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism: A systematic review and meta-analysis. Artif Organs 2021; 45:569-576. [PMID: 33277695 DOI: 10.1111/aor.13876] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents a therapeutic option for cardiopulmonary support in patients with high-risk pulmonary embolism (PE); however, no definite consensus exists on ECMO use in high-risk PE. Hence, we aim to provide insights into its real-world use pooling together all available published experiences. We performed a systematic review and pooled analysis of all published studies (up to April 17, 2020) investigating ECMO support in high-risk PE. All studies including at least four patients were collectively analyzed. Study outcomes were early all-cause death (primary endpoint) and relevant in-hospital adverse events. A total of 21 studies were included in the pooled analysis (n = 635 patients). In this population (mean age 47.8 ± 17.3 years, 44.5% females), ECMO was indicated for cardiac arrest in 62.3% and immediate ECMO support was pursued in 61.9% of patients. Adjunctive reperfusion therapies were implemented in 57.0% of patients. Pooled estimate rate of early all-cause mortality was 41.1% (95% CI 27.7%-54.5%). The most common in-hospital adverse event was major bleeding, with an estimated rate of 28.6% (95%CI 21.0%-36.3%). At meta-regression analyses, no significant impact of multiple covariates on the primary endpoint was found. In this systematic review of patients who received ECMO for high-risk PE, pooled all-cause mortality was 41.1%. Principal indication for ECMO was cardiac arrest, cannulation was chiefly performed at presentation, and major bleeding was the most common complication.
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Affiliation(s)
- Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Moroni
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Venuti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Torino, Italy
| | - Matteo Pagnesi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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86
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Massive pulmonary embolism in a patient with nephrotic syndrome and single lung. J Thromb Thrombolysis 2021; 52:680-682. [PMID: 33387209 DOI: 10.1007/s11239-020-02350-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/19/2020] [Indexed: 10/22/2022]
Abstract
We present a novel case of a patient with nephrotic syndrome and previous left pneumonectomy who had a massive pulmonary embolism of his remnant right pulmonary artery. He underwent surgical embolectomy and veno-arterial extracorporeal membrane oxygenation (ECMO). Early embolectomy using retrograde pulmonary perfusion and post-operative ECMO helped the patient survive this catastrophic event.
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87
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Ozgur S, Aksay E, Kacar AA. A rare complication of extracorporeal membrane oxygenation and thrombolytic treatment in a patient with massive pulmonary embolism: Intraperitoneal hemorrhage. Turk J Emerg Med 2021; 21:34-37. [PMID: 33575514 PMCID: PMC7864125 DOI: 10.4103/2452-2473.301916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/14/2020] [Accepted: 07/29/2020] [Indexed: 12/14/2022] Open
Abstract
Massive pulmonary embolism (PE) is one of the important emergencies that needs aggressive treatment for decreasing the risk of death. Extracorporeal membrane oxygenation (ECMO) and fibrinolysis should be considered in patients with failure in oxygenation and perfusion despite invasive mechanical ventilation and vasopressor treatment. We present the case of a 22-year-old male who underwent ECMO, systemic fibrinolysis, and cardiopulmonary resuscitation because of massive PE and subsequently developed intraperitoneal bleeding.
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Affiliation(s)
- Sefer Ozgur
- Department of Emergency Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Ersin Aksay
- Department of Emergency Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey
| | - Aysen Aydın Kacar
- Department of Emergency Medicine, Dokuz Eylul University School of Medicine, Izmir, Turkey
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88
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Gangaraju R, Klok FA. Advanced therapies and extracorporeal membrane oxygenation for the management of high-risk pulmonary embolism. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:195-200. [PMID: 33275707 PMCID: PMC7727511 DOI: 10.1182/hematology.2020000167] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Affiliation(s)
- Radhika Gangaraju
- Division of Hematology-Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL; and
| | - Frederikus A. Klok
- Department of Medicine—Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
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89
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Stewart LK, Kline JA. Fibrinolytics for the treatment of pulmonary embolism. Transl Res 2020; 225:82-94. [PMID: 32434005 PMCID: PMC7487055 DOI: 10.1016/j.trsl.2020.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 04/07/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022]
Abstract
The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.
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Affiliation(s)
- Lauren K Stewart
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana; Department of Cellular and Integrative Physiology, Indiana University School of Medicine, Indianapolis, Indiana
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90
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Carroll BJ, Beyer SE, Mehegan T, Dicks A, Pribish A, Locke A, Godishala A, Soriano K, Kanduri J, Sack K, Raber I, Wiest C, Balachandran I, Marcus M, Chu L, Hayes MM, Weinstein JL, Bauer KA, Secemsky EA, Pinto DS. Changes in Care for Acute Pulmonary Embolism Through A Multidisciplinary Pulmonary Embolism Response Team. Am J Med 2020; 133:1313-1321.e6. [PMID: 32416175 PMCID: PMC8076889 DOI: 10.1016/j.amjmed.2020.03.058] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 03/23/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Optimal management of acute pulmonary embolism requires expertise offered by multiple subspecialties. As such, pulmonary embolism response teams (PERTs) have increased in prevalence, but the institutional consequences of a PERT are unclear. METHODS We compared all patients that presented to our institution with an acute pulmonary embolism in the 3 years prior to and 3 years after the formation of our PERT. The primary outcome was in-hospital pulmonary embolism-related mortality before and after the formation of the PERT. Sub-analyses were performed among patients with elevated-risk pulmonary embolism. RESULTS Between August 2012 and August 2018, 2042 patients were hospitalized at our institution with acute pulmonary embolism, 884 (41.3%) pre-PERT implementation and 1158 (56.7%) post-PERT implementation, of which 165 (14.2%) were evaluated by the PERT. There was no difference in pulmonary embolism-related mortality between the two time periods (2.6% pre-PERT implementation vs 2.9% post-PERT implementation, P = .89). There was increased risk stratification assessment by measurement of cardiac biomarkers and echocardiograms post-PERT implementation. Overall utilization of advanced therapy was similar between groups (5.4% pre-PERT implementation vs 5.4% post-PERT implementation, P = 1.0), with decreased use of systemic thrombolysis (3.8% pre-PERT implementation vs 2.1% post-PERT implementation, P = 0.02) and increased catheter-directed therapy (1.3% pre-PERT implementation vs 3.3% post-PERT implementation, P = 0.05) post-PERT implementation. Inferior vena cava filter use decreased after PERT implementation (10.7% pre-PERT implementation vs 6.9% post-PERT implementation, P = 0.002). Findings were similar when analyzing elevated-risk patients. CONCLUSION Pulmonary embolism response teams may increase risk stratification assessment and alter application of advanced therapies, but a mortality benefit was not identified.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
| | - Sebastian E Beyer
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Tyler Mehegan
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Andrew Dicks
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Abby Pribish
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Andrew Locke
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Anuradha Godishala
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Kevin Soriano
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Jaya Kanduri
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Kelsey Sack
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Inbar Raber
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Cara Wiest
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Isabel Balachandran
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Mason Marcus
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Louis Chu
- Division of Cardiac Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Margaret M Hayes
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Jeff L Weinstein
- Division of Interventional Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Kenneth A Bauer
- Division of Hematology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Eric A Secemsky
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Duane S Pinto
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
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91
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Sertic F, Diagne D, Chavez L, Richards T, Berg A, Acker M, Giri JS, Szeto WY, Khandhar S, Gutsche J, Pugliese S, Fiorilli P, Rame E, Bermudez C. Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism. Eur J Cardiothorac Surg 2020; 58:923-931. [PMID: 32725134 DOI: 10.1093/ejcts/ezaa189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.
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Affiliation(s)
- Federico Sertic
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dieynaba Diagne
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lexy Chavez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Richards
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Berg
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Acker
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay S Giri
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sameer Khandhar
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Gutsche
- Department of Intensive Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Pugliese
- Department of Medicine, Division of Pulmonology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Fiorilli
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eduardo Rame
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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92
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QiMin W, LiangWan C, DaoZhong C, HanFan Q, ZhongYao H, XiaoFu D, XueShan H, Feng L, HuaBin C. Clinical outcomes of acute pulmonary embolectomy as the first-line treatment for massive and submassive pulmonary embolism: a single-centre study in China. J Cardiothorac Surg 2020; 15:321. [PMID: 33087152 PMCID: PMC7576708 DOI: 10.1186/s13019-020-01364-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/05/2020] [Indexed: 12/04/2022] Open
Abstract
Background Acute 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. Methods A 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. Results Overall, 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. Conclusions SPE 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.
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Affiliation(s)
- Wang QiMin
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China.
| | - Chen LiangWan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Chen DaoZhong
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Qiu HanFan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Huang ZhongYao
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Dai XiaoFu
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Huang XueShan
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Lin Feng
- Department of Cardiovascular Surgery, Union Hospital of Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Chen HuaBin
- Fujian Medical University, Fuzhou, 350001, Fujian, China
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93
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Abstract
Purpose of the Review Over 100,000 cardiovascular-related deaths annually are caused by acute pulmonary embolism (PE). While anticoagulation has historically been the foundation for treatment of PE, this review highlights the recent rapid expansion in the interventional strategies for this condition. Recent Findings At the time of diagnosis, appropriate risk stratification helps to accurately identify patients who may be candidates for advanced therapeutic interventions. While systemic thrombolytics (ST) is the mostly commonly utilized intervention for high-risk PE, the risk profile of ST for intermediate-risk PE limits its use. Assessment of an individualized patient risk profile, often via a multidisciplinary pulmonary response team (PERT) model, there are various interventional strategies to consider for PE management. Novel therapeutic options include catheter-directed thrombolysis, catheter-based embolectomy, or mechanical circulatory support for certain high-risk PE patients. Current data has established safety and efficacy for catheter-based treatment of PE based on surrogate outcome measures. However, there is limited long-term data or prospective comparisons between treatment modalities and ST. While PE diagnosis has improved with modern cross-sectional imaging, there is interest in improved diagnostic models for PE that incorporate artificial intelligence and machine learning techniques. Summary In patients with acute pulmonary embolism, after appropriate risk stratification, some intermediate and high-risk patients should be considered for interventional-based treatment for PE.
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94
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Chen YY, Chen YC, Wu CC, Yen HT, Huang KR, Sheu JJ, Lee FY. Clinical course and outcome of patients with acute pulmonary embolism rescued by veno-arterial extracorporeal membrane oxygenation: a retrospective review of 21 cases. J Cardiothorac Surg 2020; 15:295. [PMID: 33008478 PMCID: PMC7532628 DOI: 10.1186/s13019-020-01347-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 01/21/2023] Open
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. Methods Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. Results Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). Conclusions ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.
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Affiliation(s)
- Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan.
| | - Yin-Chia Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
| | - Fan-Yen Lee
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, 123, Ta-Pei Road, NiaoSung, Kaohsiung City, 83301, Taiwan
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95
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Camen S, Söffker G, Kluge S, Zengin E. Massive pulmonary embolism with intra-hospital cardiac arrest and full recovery of right ventricular function after veno-arterial extracorporeal membrane oxygenation therapy: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32974460 DOI: 10.1093/ehjcr/ytaa168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 01/29/2020] [Accepted: 05/20/2020] [Indexed: 11/14/2022]
Abstract
Background Massive pulmonary embolism (PE) with shock constitutes a life-threatening disease, challenging physicians with the need for fast decision-making in an emergency situation. While thrombolytic treatment or thrombectomy are considered the treatment of choice in high-risk PE, these strategies might not be able to unload the right ventricle (RV) fast enough in some patients with severe cardiogenic shock. Case summary We present a case of a patient with massive bilateral central PE who presented in cardiogenic shock, rapidly deteriorating to cardiac arrest. After successful re-establishing spontaneous circulation, the patient remained highly unstable, necessitating a treatment strategy ensuring a quick stabilization of the circulation. Therefore, we decided to use veno-arterial extracorporeal membrane oxygenation (vaECMO) as a supportive strategy allowing for autolysis of the lung to dissolve the thrombi (bridge to recovery). We were able to wean the patient from vaECMO support within 4 days and documented a complete recovery of right ventricular in echocardiography before hospital discharge. Discussion The concept of vaECMO treatment alone might be a valuable alternative in selected patients with massive PE and cardiogenic shock, in whom thrombolytic therapy might not unload the RV fast enough.
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Affiliation(s)
- Stephan Camen
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Building O70, Martinistrasse 52, 20246 Hamburg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Elvin Zengin
- Clinic for Cardiology, University Heart and Vascular Center Hamburg, Building O70, Martinistrasse 52, 20246 Hamburg, Germany
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96
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Delmas C, Aissaoui N, Meneveau N, Bouvaist H, Rousseau H, Puymirat E, Sapoval M, Flecher E, Meyer G, Sanchez O, Del Giudice C, Roubille F, Bonello L. Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology. Arch Cardiovasc Dis 2020; 113:749-759. [PMID: 32978090 DOI: 10.1016/j.acvd.2020.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 01/21/2023]
Abstract
Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.
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Affiliation(s)
- Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Inserm UMR 1048, Institute of Metabolic and Cardiovascular Diseases (I2MC), 31432 Toulouse, France
| | - Nadia Aissaoui
- Critical Care Unit, Penn State Heart and Vascular Institute (HVI), Hershey Medical Center (HMC) and Penn State University, 17033 PA, USA; Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen George Pompidou, AP-HP, 75015 Paris, France
| | - Nicolas Meneveau
- Department of Cardiology, EA3920, University Hospital Jean Minjoz, 25000 Besancon, France
| | - Helene Bouvaist
- Department of Cardiology, Pôle Thorax et Vaisseaux, CHU Grenoble Alpes, 38700 La Tronche, France
| | - Hervé Rousseau
- Department of Radiology, Hôpital Rangueil 1, CHU de Toulouse, 31059 Toulouse, France
| | - Etienne Puymirat
- Intensive Cardiac Care Unit, Department of Cardiology, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Marc Sapoval
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - Erwan Flecher
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Inserm UMR 1099, 35000 Rennes, France
| | - Guy Meyer
- Department of Pneumology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris and CIC 1418, 75015 Paris, France
| | - Olivier Sanchez
- Department of Pulmonology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, Inserm UMRS 1140, Université de Paris, 75270 Paris, France
| | - Costantino Del Giudice
- Vascular and Oncological Interventional Radiology, Inserm U970, Paris Cardiovascular Research Centre, Hôpital Européen Georges Pompidou, AP-HP, 75015 Paris, France
| | - François Roubille
- Department of Cardiology, CHU de Montpellier, Université de Montpellier, Inserm, CNRS, 34295 Montpellier, France
| | - Laurent Bonello
- Intensive Care Unit, Department of Cardiology, Hôpital Nord, AP-HM, Aix-Marseille Université, 13015 Marseille; Mediterranean Association for Research and Studies in Cardiology (MARS Cardio), 13000 Marseille, France; INSERM 1263, 1260, Centre for Cardiovascular and Nutrition Research (C2VN), INRA, 13385 Marseille, France.
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97
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Badulak JH, Shinar Z. Extracorporeal Membrane Oxygenation in the Emergency Department. Emerg Med Clin North Am 2020; 38:945-959. [PMID: 32981628 DOI: 10.1016/j.emc.2020.06.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a mechanical way to provide oxygenation, ventilation, and perfusion to patients with severe cardiopulmonary failure. Extracorporeal cardiopulmonary resuscitation (ECPR) describes the use of ECMO during cardiac arrest. ECPR requires an organized approach to resuscitation, cannula insertion, and pump initiation. Selecting the right patients for ECPR is an important aspect of successful programs. A solid understanding of the components of the ECMO circuit is critical to troubleshooting problems. Current evidence suggests a substantial benefit of ECPR compared with traditional CPR for refractory cardiac arrest but is limited by lack of randomized trials to date.
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Affiliation(s)
- Jenelle H Badulak
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Emergency Medicine, University of Washington, Harborview Medical Center, Box 359702, 325 Ninth Avenue, Seattle, WA 98104-2499, USA.
| | - Zachary Shinar
- Department of Emergency Medicine, Sharp Memorial Hospital, 7901 Frost Street, San Diego, CA 92130, USA. https://twitter.com/ZackShinar
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98
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Fryk K, Rylander C, Svennerholm K. Repeated and adaptive multidisciplinary assessment of a patient with acute pulmonary embolism and recurrent cardiac arrests. BMJ Case Rep 2020; 13:13/9/e234647. [PMID: 32878851 DOI: 10.1136/bcr-2020-234647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
High-risk pulmonary embolism (PE) is a life-threatening condition that must be recognised and treated rapidly. The importance of correct risk stratification to guide therapeutic decisions has prompted the introduction of multidisciplinary PE response teams (PERTs). The recommended first-line treatment for high-risk PE is intravenous thrombolysis. Alternatives to consider if thrombolysis has insufficient effect or may cause significant haemorrhagic complications include catheter-directed intervention (CDI) and surgical thrombectomy. For patients in deep shock or cardiac arrest, veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can be instituted for cardiopulmonary rescue and support during CDI, thrombectomy or pharmacological treatment. We present a complex case of high-risk PE that illustrates the importance of an early PERT conference and repeated decision-making when the initial therapy fails. After a trial of thrombolysis with insufficient effect, VA-ECMO was used to reverse circulatory and respiratory collapse in a patient with PE and recurrent episodes of cardiac arrest.
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Affiliation(s)
- Karin Fryk
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Christian Rylander
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Kristina Svennerholm
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Goteborg, Sweden
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99
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Konstantinides S, Meyer G. Management of acute pulmonary embolism 2019: what is new in the updated European guidelines? Intern Emerg Med 2020; 15:957-966. [PMID: 32458205 PMCID: PMC7467952 DOI: 10.1007/s11739-020-02340-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 04/08/2020] [Indexed: 12/11/2022]
Abstract
Pulmonary embolism (PE) is the third most frequent acute cardiovascular syndrome. Annual PE incidence and PE-related mortality rates rise exponentially with age, and consequently, the disease burden imposed by PE on the society continues to rise as the population ages worldwide. Recently published landmark trials provided the basis for new or changed recommendations included in the 2019 update of the European Society of Cardiology Guidelines (developed in cooperation with the European Respiratory Society). Refinements in diagnostic algorithms were proposed and validated, increasing the specificity of pre-test clinical probability and D-dimer testing, and thus helping to avoid unnecessary pulmonary angiograms. Improved diagnostic strategies were also successfully tested in pregnant women with suspected PE. Non-vitamin K antagonist oral anticoagulants (NOACs) are now the preferred agents for treating the majority of patients with PE, both in the acute phase (with or without a brief lead-in period of parenteral heparin or fondaparinux) and over the long term. Primary reperfusion is reserved for haemodynamically unstable patients. Besides, the 2019 Guidelines endorse multidisciplinary teams for coordinating the acute-phase management of high-risk and (in selected cases) intermediate-risk PE. For normotensive patients, physicians are advised to include the assessment of the right ventricle on top of clinical severity scores in further risk stratification, especially if early discharge of the patient is envisaged. Further important updates include guidance (1) on extended anticoagulation after PE, taking into account the improved safety profile of NOACs; and (2) on the overall care and follow-up of patients who have suffered PE, with the aim to prevent, detect and treat late sequelae of venous thromboembolism.
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Affiliation(s)
- Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Langenbeckstrasse 1, Bldg. 403, 55131 Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Guy Meyer
- Respiratory Medicine Department, Hôpital Européen Georges Pompidou, APHP, Paris, France
- Université Paris Descartes, 75006 Paris, France
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100
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Goldhaber SZ. ECMO and Surgical Embolectomy: Two Potent Tools to Manage High-Risk Pulmonary Embolism. J Am Coll Cardiol 2020; 76:912-915. [PMID: 32819464 DOI: 10.1016/j.jacc.2020.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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