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Liu Z, Chen J, Xu X, Lan F, He M, Shao C, Xu Y, Han P, Chen Y, Zhu Y, Huang M. Extracorporeal Membrane Oxygenation—First Strategy for Acute Life-Threatening Pulmonary Embolism. Front Cardiovasc Med 2022; 9:875021. [PMID: 35722115 PMCID: PMC9203845 DOI: 10.3389/fcvm.2022.875021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 05/09/2022] [Indexed: 11/25/2022] Open
Abstract
Background Both venoarterial extracorporeal membrane oxygenation (VA-ECMO) and percutaneous mechanical thrombectomy (PMT) are increasingly used to treat acute life-threatening pulmonary embolism (PE). However, there are little data regarding their effectiveness. This study aimed to present the short-term outcomes after managing nine patients with acute life-threatening massive or submassive PE by VA-ECMO with or without complemented PMT and propose a preliminary treatment algorithm. Methods This study was a single-center retrospective review of a prospectively maintained registry. It included nine consecutive patients with massive or submassive pulmonary embolism who underwent VA-ECMO for initial hemodynamic stabilization, with or without PMT, from August 2018 to November 2021. Results Mean patient age was 54.7 years. Four of nine patients (44.4%) required cardiopulmonary resuscitation before or during VA-ECMO cannulation. All cannulations (100%) were successfully performed percutaneously. Overall survival was 88.9% (8 of 9 patients). One patient died from a hemorrhagic stroke. Of the survivors, the median ECMO duration was 8 days in patients treated with ECMO alone and 4 days in those treated with EMCO and PMT. Five of nine patients (55.6%) required concomitant PMT to address persistent right heart dysfunction, with the remaining survivors (44.4%) receiving VA-ECMO and anticoagulation alone. For survivors receiving VA-ECMO plus PMT, median hospital lengths of stay were 7 and 13 days, respectively. Conclusions An ECMO-first strategy complemented with PMT can be performed effectively and safely for acute life-threatening massive or submassive PE. VA-ECMO is feasible for initial stabilization, serving as a bridge to therapy primarily in inoperable patients with massive PE. Further evaluation in a larger cohort of patients is warranted to assess whether VA-ECMO plus PMT may offer an alternative or complementary therapy to thrombolysis or surgical thrombectomy. Type of Research Single-center retrospective review of a prospectively maintained registry.
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Affiliation(s)
- Zhenjie Liu
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Zhenjie Liu
| | - Jinyi Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xin Xu
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Fen Lan
- Department of Respiratory Medicine, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Minzhi He
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Changming Shao
- Department of Vascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yongshan Xu
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Pan Han
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yibing Chen
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yongbin Zhu
- Medical Department, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Yongbin Zhu
| | - Man Huang
- Intensive Care Unit, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
- Man Huang
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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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Yakar A, Yakar F, Atacan SÇ, Yıldız M, Üzün İ. Failure of Therapy at Premortem Diagnosed Pulmonary Thromboembolism. JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2016. [DOI: 10.5799/jcei.328615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Yakar A, Yakar F, Ziyade N, Yıldız M, Üzün İ. Cardiac Findings of Pulmonary Thromboembolism by Autopsy: A Review of 48 Cases. Med Sci Monit 2016; 22:1410-4. [PMID: 27117720 PMCID: PMC4913817 DOI: 10.12659/msm.897695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background To identify the overall effects of pulmonary thromboembolism (PTE) on the heart, we evaluated the heart findings and clinical characteristics of deceased patients diagnosed with PTE. Material/Methods PTEs were classified into 2 categories: fatal and contributory. Cases with a history of cardiopulmonary disease or a finding of significant disease at autopsy, including valvular heart disease and coronary artery obstruction >50%, were excluded from the cardiac evaluation. We defined an LV wall ≥1.2 cm thick and an RV wall ≥0.8 cm thick as abnormal. Results Forty-eight cases were included to the study (21 males and 27 females). The mean age was 41.42±16.5 years. Of the 48 cases, 5 were excluded due to cardiopulmonary diseases for determining heart findings. The thicknesses of the LV and RV walls were not measured in some patients. In the 43 cases, cardiac hypertrophy was detected in 28 patients (65.1%). The mean heart weight was 387±83.5 g. The mean thickness of the left ventricle (LV) wall was 1.40±0.41 cm in 40 cases, and the mean thickness of the RV wall was 0.41±0.135 cm in 41 cases. The LV walls of 35 (87.5%) cases and the RV walls of 2 cases met criteria for abnormal wall thickness. There were histopathological findings of heart in 24/43 cases (56%); these findings were necrosis, fibrosis, and hypertrophy. Conclusions The RV is affected by massive pulmonary embolism; however, the LV may also play a role in the pathogenesis of PTE.
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Affiliation(s)
- Aysun Yakar
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
| | - Fatih Yakar
- Department of Pulmonary Medicine, Bezmialem Vakif University, Medical Faculty, Istanbul, Turkey
| | - Nihan Ziyade
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
| | - Muhlis Yıldız
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
| | - İbrahim Üzün
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
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Lagos-Carvajal AP, Teixeira-Neto FJ, Becerra-Velásquez DR, Diniz MS, Klein AV, Rocha TLA, Dias-Junior CA. Adrenomedullin induces pulmonary vasodilation but does not attenuate pulmonary hypertension in a sheep model of acute pulmonary embolism. Life Sci 2015; 139:139-44. [PMID: 26316450 DOI: 10.1016/j.lfs.2015.08.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 08/05/2015] [Accepted: 08/17/2015] [Indexed: 11/19/2022]
Abstract
AIMS The pulmonary vasodilation induced by adrenomedullin may be beneficial in the acute pulmonary embolism (APE) setting. This study examined effects of adrenomedullin in sheep with microsphere-induced APE. MAIN METHODS Twenty four anesthetized, mechanically ventilated sheep were randomly assigned into 3 groups (n=8 per group): animals not subjected to any intervention (Sham), animals with APE induced by microspheres (500 mg, intravenously) treated 30 min later by intravenous physiological saline (Emb group) or intravenous adrenomedullin (50 ng/kg/min) during 30 min (Emb+Adm group). Plasma concentrations of cyclic adenosine (cAMP) and guanosine monophosphate (cGMP) were determined by enzyme immunoassay. KEY FINDINGS Variables did not change over time in sham animals. In both embolized groups, microsphere injection significantly (P<0.05) increased pulmonary vascular resistance index (PVRI) and mean pulmonary artery pressure (MPAP) from baseline by 181% and 111-142%, respectively (% change in mean values). Adrenomedullin significantly decreased PVRI (18%-25%) and significantly increased cardiac index (22%-25%) from values recorded 30 min after APE (E30), without modifying MPAP. Adrenomedullin decreased mean arterial pressure (18%-24%) and systemic vascular resistance index (32%-40%). Embolization significantly increased arterial-to-end tidal CO2 gradient, alveolar-to-arterial O2 gradient, and pulmonary shunt fraction from baseline, but these variables were unaffected by adrenomedullin. While adrenomedullin significantly increased plasma cAMP, cGMP levels were unaltered. SIGNIFICANCE Adrenomedullin induces systemic and pulmonary vasodilation, possibly via a cAMP mediated mechanism, without modifying the gas exchange impairment associated with APE. The pulmonary anti-hypertensive effect of adrenomedullin may be offset by increases in cardiac index.
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Affiliation(s)
- Angie Paola Lagos-Carvajal
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Francisco José Teixeira-Neto
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil; Departamento de Cirurgia e Anestesiologia Veterinária, Faculdade de Medicina Veterinária e Zootecnia, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Diana Rocío Becerra-Velásquez
- Departamento de Cirurgia e Anestesiologia Veterinária, Faculdade de Medicina Veterinária e Zootecnia, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Miriely Steim Diniz
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Adriana Vieira Klein
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Thalita Leone Alves Rocha
- Departamento de Farmacologia, Instituto de Biociências de Botucatu, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil
| | - Carlos Alan Dias-Junior
- Departamento de Anestesiologia, Faculdade de Medicina, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil; Departamento de Farmacologia, Instituto de Biociências de Botucatu, Univ. Estadual Paulista (UNESP), Botucatu, São Paulo, Brazil.
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Effects of different inspired oxygen fractions on sildenafil-induced pulmonary anti-hypertensive effects in a sheep model of acute pulmonary embolism. Life Sci 2015; 127:26-31. [DOI: 10.1016/j.lfs.2015.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Revised: 01/21/2015] [Accepted: 02/02/2015] [Indexed: 11/22/2022]
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Abstract
Acute respiratory distress syndrome (ARDS) is characterised by diffuse alveolar damage and is frequently complicated by pulmonary hypertension (PH). Multiple factors may contribute to the development of PH in this setting. In this review, we report the results of a systematic search of the available peer-reviewed literature for papers that measured indices of pulmonary haemodynamics in patients with ARDS and reported on mortality in the period 1977 to 2010. There were marked differences between studies, with some reporting strong associations between elevated pulmonary arterial pressure or elevated pulmonary vascular resistance and mortality, whereas others found no such association. In order to discuss the potential reasons for these discrepancies, we review the physiological concepts underlying the measurement of pulmonary haemodynamics and highlight key differences between the concepts of resistance in the pulmonary and systemic circulations. We consider the factors that influence pulmonary arterial pressure, both in normal lungs and in the presence of ARDS, including the important effects of mechanical ventilation. Pulmonary arterial pressure, pulmonary vascular resistance and transpulmonary gradient (TPG) depend not alone on the intrinsic properties of the pulmonary vascular bed but are also strongly influenced by cardiac output, airway pressures and lung volumes. The great variability in management strategies within and between studies means that no unified analysis of these papers was possible. Uniquely, Bull et al. (Am J Respir Crit Care Med 182:1123-1128, 2010) have recently reported that elevated pulmonary vascular resistance (PVR) and TPG were independently associated with increased mortality in ARDS, in a large trial with protocol-defined management strategies and using lung-protective ventilation. We then considered the existing literature to determine whether the relationship between PVR/TPG and outcome might be causal. Although we could identify potential mechanisms for such a link, the existing evidence does not allow firm conclusions to be drawn. Nonetheless, abnormally elevated PVR/TPG may provide a useful index of disease severity and progression. Further studies are required to understand the role and importance of pulmonary vascular dysfunction in ARDS in the era of lung-protective ventilation.
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Swaminathan A. Massive and submassive pulmonary embolism: diagnostic challenges and thrombolytic therapy. Acad Emerg Med 2014; 21:208-10. [PMID: 24438552 DOI: 10.1111/acem.12301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Neto-Neves EM, Sousa-Santos O, Ferraz KC, Rizzi E, Ceron CS, Romano MMD, Gali LG, Maciel BC, Schulz R, Gerlach RF, Tanus-Santos JE. Matrix metalloproteinase inhibition attenuates right ventricular dysfunction and improves responses to dobutamine during acute pulmonary thromboembolism. J Cell Mol Med 2013; 17:1588-97. [PMID: 24199964 PMCID: PMC3914650 DOI: 10.1111/jcmm.12163] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 09/16/2013] [Indexed: 02/06/2023] Open
Abstract
Activated matrix metalloproteinases (MMPs) cause cardiomyocyte injury during acute pulmonary thromboembolism (APT). However, the functional consequences of this alteration are not known. We examined whether doxycycline (a MMP inhibitor) improves right ventricle function and the cardiac responses to dobutamine during APT. APT was induced with autologous blood clots (350 mg/kg) in anaesthetized male lambs pre-treated with doxycycline (Doxy, 10 mg/kg/day, intravenously) or saline. Non-embolized control lambs received doxycycline pre-treatment or saline. The responses to intravenous dobutamine (Dob, 1, 5, 10 μg/kg/min.) or saline infusions at 30 and 120 min. after APT induction were evaluated by echocardiography. APT increased mean pulmonary artery pressure and pulmonary vascular resistance index by ∼185%. Doxycycline partially prevented APT-induced pulmonary hypertension (P < 0.05). RV diameter increased in the APT group (from 10.7 ± 0.8 to 18.3 ± 1.6 mm, P < 0.05), but not in the Doxy+APT group (from 13.3 ± 0.9 to 14.4 ± 1.0 mm, P > 0.05). RV dysfunction on stress echocardiography was observed in embolized lambs (APT+Dob group) but not in embolized animals pre-treated with doxycycline (Doxy+APT+Dob). APT increased MMP-9 activity, oxidative stress and gelatinolytic activity in the RV. Although doxycycline had no effects on RV MMP-9 activity, it prevented the increases in RV oxidative stress and gelatinolytic activity (P < 0.05). APT increased serum cardiac troponin I concentrations (P < 0.05), doxycycline partially prevented this alteration (P < 0.05). We found evidence to support that doxycycline prevents RV dysfunction and improves the cardiac responses to dobutamine during APT.
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Affiliation(s)
- Evandro M Neto-Neves
- Department of Pharmacology, Faculty of Medicine of Ribeirao Preto, University of Sao Paulo, Ribeirao Preto, Brazil
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