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Kaymaz C, Akbal OY, Keskin B, Tokgoz HC, Hakgor A, Karagoz A, Tanyeri S, Kultursay B, Kulahcioglu S, Dogan C, Bayram Z, Efe SÇ, Erkılınç A, Tanboga IH, Akbulut M, Ozdemir N, Tapson V, Konstantinides S. An Eight-year, Single-center Experience on Ultrasound Assisted Thrombolysis with Moderate-dose, Slow-infusion Regimen in Pulmonary Embolism. Curr Vasc Pharmacol 2022; 20:370-378. [PMID: 36324223 DOI: 10.2174/1570161120666220428095705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/19/2022] [Accepted: 03/10/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND There is limited data on moderate-dose with slow-infusion thrombolytic regimen by ultrasound-asssisted-thrombolysis (USAT) in patients with acute pulmonary embolism (PE). AIMS In this study, our eight-year experience on USAT with moderate-dose, slow-infusion tissue-type plasminogen activator (t-PA) regimen in patients with PE at intermediate-high- and high-risk was presented, and short-, and long-term effectiveness and safety outcomes were evaluated. METHODS Our study is based on the retrospective evaluation of 225 patients with PE having multiple comorbidities who underwent USAT. RESULTS High- and intermediate-high-risk were noted in 14.7% and in 85.3% of patients, respectively. Mean t-PA dosage was 35.4±13.3 mg, and the infusion duration was 26.6±7.7 h. Measures of pulmonary artery (PA) obstruction and right ventricle (RV) dysfunction were improved within days (p<0.0001 for all). During the hospital stay, major and minor bleeding and mortality rates were 6.2%, 12.4%, and 6.2%, respectively. Bleeding and unresolved PE accounted for 50% and 42.8% of in-hospital mortality, respectively. Age, rate, and duration of t-PA were not associated with in-hospital major bleeding and mortality. Oxygen saturation exceeded 90% in 91.2% of patients at discharge. During follow-up of median 962 (610-1894) days, high-risk status related to 30-day mortality, whereas age >65 years was associated with long-term mortality. CONCLUSION Our real-life experience with USAT with moderate-dose, slow-infusion t-PA regimen in patients with PE at high-and intermediate-high risk demonstrated clinically relevant improvements in PA obstructive burden and RV dysfunction. Age, rate or infusion duration of t-PA was not related to major bleeding or mortality risk, whereas unresolved obstruction remained as a lethal issue.
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Affiliation(s)
- Cihangir Kaymaz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ozgur Yasar Akbal
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Berhan Keskin
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Hacer Ceren Tokgoz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Aykun Hakgor
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Ali Karagoz
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Seda Tanyeri
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Barkın Kultursay
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Seyhmus Kulahcioglu
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Cem Dogan
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Zubeyde Bayram
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Süleyman Çağan Efe
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Atakan Erkılınç
- Department of Anesthesiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | | | - Mehmet Akbulut
- Faculty of Medicine, Department of Cardiology, Fırat University, Elâzığ, Turkey
| | - Nihal Ozdemir
- Department of Cardiology, Kosuyolu Heart Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Victor Tapson
- Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
| | - Stavros Konstantinides
- Department of Cardiology, Democritus University Medical School, Thrace, Greece.,Centre for Thrombosis and Haemostasis, University Medical Centre Mainz, Johannes Gutenberg-University, Mainz, Germany
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Abstract
Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.
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Affiliation(s)
- Abby M Pribish
- Department of Medicine, Division of ADM-Housestaff, Beth Israel Deaconess Medical Center, Harvard Medical School, Deac 311, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Alec A Schmaier
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA.
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Valerio L, Klok FA, Barco S. Immediate and late impact of reperfusion therapies in acute pulmonary embolism. Eur Heart J Suppl 2019; 21:I1-I13. [PMID: 31777451 PMCID: PMC6868376 DOI: 10.1093/eurheartj/suz222] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Haemodynamic instability and right ventricular dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). Residual thrombi and persistent right ventricular dysfunction may contribute to post-PE functional impairment, and influence the risk of developing chronic thromboembolic pulmonary hypertension. Patients with haemodynamic instability at presentation (high-risk PE) require immediate primary reperfusion to relieve the obstruction in the pulmonary circulation and increase the chances of survival. Surgical removal of the thrombi or catheter-directed reperfusion strategies is alternatives in patients with contraindications to systemic thrombolysis. For haemodynamically stable patients with signs of right ventricular overload or dysfunction (intermediate-risk PE), systemic standard-dose thrombolysis is currently not recommended, because the risk of major bleeding associated with the treatment outweighs its benefits. In such cases, thrombolysis should be considered only as a rescue intervention if haemodynamic decompensation develops. Catheter-directed pharmaco-logical and pharmaco-mechanical techniques ensure swift recovery of echocardiographic and haemodynamic parameters and may be characterized by better safety profile than systemic thrombolysis. For survivors of acute PE, little is known on the effects of reperfusion therapies on the risk of chronic functional and haemodynamic impairment. In intermediate-risk PE patients, available data suggest that systemic thrombolysis may have little impact on long-term symptoms and functional limitation, echocardiographic parameters, and occurrence of chronic thromboembolic pulmonary hypertension. Ongoing and future interventional studies will clarify whether ‘safer’ reperfusion strategies may improve early clinical outcomes without increasing the risk of bleeding and contribute to reducing the burden of long-term complications after intermediate-risk PE.
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Affiliation(s)
- Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstraße 1, Building 403, 55131 Mainz, Germany
| | - Frederikus A Klok
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstraße 1, Building 403, 55131 Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Langenbeckstraße 1, Building 403, 55131 Mainz, Germany
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Zuin M, Rigatelli G, Zonzin P, Roncon L. Inferior Vena Cava Filters in Hemodynamically Unstable Patients with Acute Pulmonary Embolism: How Often are They Used? Data from Multicenter Prospective Registries on Acute Pulmonary Embolism. Cardiovasc Intervent Radiol 2019; 42:1073-1079. [PMID: 31093719 DOI: 10.1007/s00270-019-02242-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 05/06/2019] [Indexed: 11/26/2022]
Abstract
The use of inferior vena cava (IVC) filters is recommended in patients with acute pulmonary embolism (PE) who have absolute contraindications to anticoagulant drugs and/or in those subjects with recurrent PE despite treated with an adequate anticoagulant regimen. During the last 2 decades, some investigations have demonstrated that the use of IVC filters in high-risk PE patients, treated or not with systemic thrombolysis, was able to reduce the short-term mortality rate if inserted early after the acute event. The aim of the present review is to analyze the use of IVC filters in high-risk PE patients enrolled in prospective multicenter registries between 1990 and 2018. After screening 3542 article in PubMed, Scopus, Cochrane library and Goggle Scholar databases, we identified four registry studies meeting the inclusion criteria. In a prospective cohort of 39,056 patients, 1387 (3.5%) were hemodynamically unstable at admission. Among them, IVC filters were used only in 2.7% of cases. Conversely, IVC filters were inserted in 3.8% of hemodynamically stable patients. Over the years, a fluctuating trend in the use of IVC filters was observed. In the absence of randomized controlled trial on this issue, which would be difficult, if not impossible to realize, data obtained from the medical literature seem to suggest that IVC filters could represent a valid adjunctive therapy in hemodynamically unstable PE patients, able to prevent further hemodynamic deterioration. Further and larger subgroup analyses, obtained both by prospective and retrospective studies, are necessary to clarify this therapeutic approach.
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Affiliation(s)
- Marco Zuin
- Section of Internal and Cardiopulmonary Medicine, University of Ferrara, Ferrara, Italy
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Gianluca Rigatelli
- Cardiovascular Diagnosis and Endoluminal Interventions Unit, Rovigo General Hospital, Rovigo, Italy
| | - Pietro Zonzin
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy
| | - Loris Roncon
- Division of Cardiology, Rovigo General Hospital, Rovigo, Italy.
- Department of Cardiology, Santa Maria della Misericordia Hospital, Viale Tre Martiri 140, 45100, Rovigo, Italy.
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Kaymaz C, Akbal OY, Hakgor A, Tokgoz HC, Karagoz A, Tanboga IH, Tanyeri S, Keskin B, Turkday S, Demir D, Dogan C, Bayram Z, Acar RD, Guvendi B, Ozdemir N, Tapson VF, Konstantinides S. A five-year, single-centre experience on ultrasound-assisted, catheter-directed thrombolysis in patients with pulmonary embolism at high risk and intermediate to high risk. EUROINTERVENTION 2018; 14:1136-1143. [DOI: 10.4244/eij-d-18-00371] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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