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Sutedja JC, Tjandra DC, Oden GF, DE Liyis BG. Resveratrol as an adjuvant prebiotic therapy in the management of pulmonary thromboembolism. Minerva Cardiol Angiol 2024; 72:416-425. [PMID: 38305013 DOI: 10.23736/s2724-5683.23.06455-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
Pulmonary thromboembolism (PTE) presents a grave threat to patient lives, often marked by arterial occlusion in the pulmonary vasculature, frequently stemming from deep vein thrombosis (DVT). While current anticoagulant therapies offer temporary relief, they fall short of addressing the long-term management of PTE. Notably, PTE-associated mortality rates continue to rise annually, positioning it as a crucial concern within the cardiovascular landscape. An intriguing suspect underlying compromised prognoses is the intricate interplay between the gut microbiome and PTE outcomes. The gut-derived metabolite, trimethylamine N-oxide (TMAO), has emerged as a direct contributor to accelerated thrombogenesis, thereby heightening PTE susceptibility. In pursuit of remedies, research has delved into diverse prebiotic and probiotic interventions, with Resveratrol (RSV) emerging as a promising candidate. This paper explores the potential of RSV, a polyphenolic compound, as an adjuvant prebiotic therapy. The proposed therapeutic approach not only augments anticoagulant potency through strategic pharmacokinetic interactions but also introduces a novel avenue for attenuating future PTE incidents through deliberate gut microbiome modulation. RSV's multifaceted attributes extend beyond its role in PTE prevention. Recognized for its anti-inflammatory, antioxidant, and cardioprotective properties, RSV stands as a versatile therapeutic candidate. It exhibits the ability to curtail platelet aggregation, augment warfarin bioavailability, and mitigate pulmonary arterial wall thickening - an ensemble of effects that substantiate its potential as an adjunct prebiotic for PTE patients. This literature review weaves together the latest insights, culminating in a compelling proposition: RSV is an instrumental player in the trajectory of PTE management.
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Affiliation(s)
- Jane C Sutedja
- Faculty of Medicine, Udayana University, Denpasar, Indonesia -
| | - David C Tjandra
- Faculty of Medicine, Udayana University, Denpasar, Indonesia
| | - Gwyneth F Oden
- Faculty of Medicine, Udayana University, Denpasar, Indonesia
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Ji J, Jiang L, Wang W, Chi X, Dong J, Lu L, Huang M, Wei X, Pang G, Pang J, Xiong B, Xiang S. AngioJet thrombectomy with extracorporeal membrane oxygenation support for an acute large-scale pulmonary embolism with bilateral atrial thrombosis: a case report of catastrophic antiphospholipid syndrome. Front Cardiovasc Med 2024; 11:1409775. [PMID: 39015680 PMCID: PMC11249738 DOI: 10.3389/fcvm.2024.1409775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Accepted: 06/11/2024] [Indexed: 07/18/2024] Open
Abstract
Background Catastrophic Antiphospholipid Syndrome (CAPS), a severe systemic autoimmune disorder, predominantly causes life-threatening multi-organ failure, with a high mortality rate. It primarily affects small vessels, seldom impacting large vessels. Notably, acute massive pulmonary embolism (PE) with bilateral atrial thrombosis is an exceptional occurrence in CAPS. Acute pulmonary embolism (PE) is a common cardiovascular disease that progresses rapidly and has a high mortality rate. Acute massive PE combined with bilateral atrial thrombosis has an even higher mortality rate. PE treatments primarily include pharmaceuticals, catheter interventions, and surgical measures, with integrated treatment strategies demonstrating promising outcomes in clinical practice. Extracorporeal membrane oxygenation (ECMO) can provide cardiopulmonary support for the treatment of high-risk PE patients and is a proven therapeutic measure. Methods This report presents the case of a 52-year-old male admitted due to fever and sudden onset of impaired consciousness, with cardiac ultrasound and pulmonary artery CT angiography revealing an acute large-scale pulmonary embolism accompanied by bilateral atrial thrombosis, with the condition rapidly worsening and manifesting severe respiratory and circulatory failure. With ECMO support, the patient underwent a thrombectomy using an AngioJet intervention. The diagnosis of CAPS was confirmed through clinical presentation and laboratory examination, and treatment was adjusted accordingly. Results The patient made a successful recovery and was subsequently discharged from the hospital. Conclusion In CAPS patients, the rare instance of acute massive PE accompanied by bilateral atrial thrombosis significantly risks severe respiratory and circulatory failure, adversely affecting prognosis. Early initiation of ECMO therapy is crucial, offering a vital opportunity to address the root cause. In this case report the patient was successfully treated with an AngioJet thrombectomy supported by ECMO.
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Affiliation(s)
- Jianyu Ji
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Lei Jiang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Wei Wang
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Xinyu Chi
- Guangxi Health Commission Key Laboratory of Diagnosis and Treatment of Acute Respiratory Distress Syndrome, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Jinda Dong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of Blood Transfusion, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Liqiu Lu
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Minyan Huang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Xiutian Wei
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Guangbao Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Jing Pang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
| | - Bin Xiong
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Research Center of Communicable and Severe Diseases, Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
| | - Shulin Xiang
- Guangxi Academy of Medical Sciences, Nanning, Guangxi, China
- Department of IntensiveCare Unit, The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, Guangxi, China
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Brewer JM, Sparling J, Maybauer MO. Venoarterial extracorporeal membrane oxygenation for "protected" catheter-based embolectomy in high-risk/massive pulmonary embolism. Perfusion 2024; 39:1009-1013. [PMID: 36998160 DOI: 10.1177/02676591231167713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
High-risk/massive pulmonary embolism (PE) has a high mortality rate, especially when cardiac arrest occurs. Venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) can rapidly restore and maintain circulation while a decision regarding further care or performance of other interventions takes place. Catheter-based embolectomy (CBE) is a technology that allows for percutaneous access, clot removal, and potential resolution of shock while avoiding sternotomy required for traditional pulmonary embolectomy. Rapid placement of V-A ECMO in patients with high-risk/massive PE prior to CBE may confer circulatory protection before, during, and after the procedure.
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Affiliation(s)
- Joseph M Brewer
- Nazih Zuhdi Transplant Institute, Advanced Cardiac Care, Specialty Critical Care and Acute Circulatory Support Service, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Jeffrey Sparling
- INTEGRIS Cardiovascular Physicians, INTEGRIS Heart Hospital, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
| | - Marc O Maybauer
- Nazih Zuhdi Transplant Institute, Advanced Cardiac Care, Specialty Critical Care and Acute Circulatory Support Service, INTEGRIS Baptist Medical Center, Oklahoma City, OK, USA
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University, Marburg, Germany
- Critical Care Research Group, Prince Charles Hospital, University of Queensland, Brisbane, Australia
- Division of Critical Care Medicine, Department of Anesthesiology, University of Florida, Gainesville, FL, USA
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Sim HT, Jo MS, Chang YJ, Cho DG, Kim JW. Outcome of massive pulmonary embolism treated only with extracorporeal membrane oxygenation and anticoagulation without thrombolytic therapy or surgical embolectomy. Perfusion 2024; 39:884-890. [PMID: 37083034 DOI: 10.1177/02676591231164878] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
INTRODUCTION Although thrombolytic therapy is the standard treatment for massive pulmonary thromboembolism (PTE), it is often ineffective in patients with circulatory collapse. Surgical embolectomy is another treatment option, but whether it is absolutely necessary is controversial. We sought to evaluate the outcomes of patients with massive PTE treated with intensive critical care including extracorporeal membrane oxygenation (ECMO) without thrombolytic therapy or surgical embolectomy. METHODS We analyzed 39 patients who were treated for massive PTE from January 2011 to June 2019. Massive PTE was treated with anticoagulation and hemodynamic support at an intensive care unit. ECMO was applied in patients with circulatory collapse. The computed tomography (CT) obstruction index and the ratio of the right ventricle to left ventricle short-axis diameters (RV/LV) were measured using serial CT angiography to confirm changes in pulmonary emboli and RV strain. RESULTS Twenty-one patients were in cardiogenic shock, and 15 of them needed cardiopulmonary resuscitation (CPR). Fifteen patients were treated with ECMO and nine of them were weaned successfully. The overall in-hospital mortality was 23% (9/39). On the follow-up CT scan after 6 months, residual PTE was observed in 10 patients and their median CT obstruction index was 6.25 % (range 2.5-35). The initial mean RV/LV ratio was 1.8 ± 0.47 and the value measured at follow-up CT decreased to less than 1 (0.9 ± 0.1). CONCLUSIONS Intensive critical care with heparin alone and timely ECMO support without thrombolytic therapy could be an effective treatment option in patients with acute massive PTE.
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Affiliation(s)
- Hyung Tae Sim
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Gyeongsang National University, Changwon, Republic of Korea
| | - Min Seop Jo
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Yong Jin Chang
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Deog Gon Cho
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Republic of Korea
| | - Jong Woo Kim
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Gyeongsang National University, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Levy D, Saura O, Passarelli MT, Lucenteforte M, Lebreton G, Bougle A, Monsel A, Ortuno S, Benitha Y, Hammoudi N, Assouline B, Petit M, Gautier M, Le Fevre L, Pineton de Chambrun M, Juvin C, Chommeloux J, Luyt CE, Hékimian G, Leprince P, Combes A, Schmidt M. Thrombolysis before venoarterial ECMO for high-risk pulmonary embolism: a retrospective cohort study. Intensive Care Med 2024:10.1007/s00134-024-07501-9. [PMID: 38913095 DOI: 10.1007/s00134-024-07501-9] [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: 03/10/2024] [Accepted: 05/21/2024] [Indexed: 06/25/2024]
Abstract
PURPOSE Despite systemic thrombolysis, a few patients with high-risk pulmonary embolism (PE) remain hemodynamically unstable. Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a considerable lifesaving therapy but systemic thrombolysis before cannulation could carry a high risk of hemorrhage and alter the prognosis. METHODS Between June 2012 and June 2023, we retrospectively analyzed from three intensive care units in Sorbonne University, ECMO-related complications and 90-day mortality for high-risk PE patients who received ECMO without previous systemic thrombolysis compared to those cannulated after systemic thrombolysis failure. Hospital discharge survivors were assessed for long-term health-related quality of life and echocardiographic evaluations. RESULTS 72 high-risk PE patients [median age 48 (37-61) years, Simplified Acute Physiology Score II (SAPS II) 74 (60-85)] were placed on VA-ECMO for 5 (5-7) days. 31 (43%) patients underwent pre-ECMO thrombolysis (thrombolysis ECMO group, T +) compared to 41 patients (57%, no thrombolysis ECMO group, T-). There was more pre-ECMO cardiac arrest in the thrombolysis ECMO group (94% vs. 67%, p = 0.02). Ninety-day survival was not different between groups (39% vs 46%, log-rank test, p = 0.31). There was no difference in severe hemorrhages (61% vs 59%, p = 1). Twenty-five over 28 patients attended follow-up at a median time of 69 (52-95) months. Long-term quality of life was acceptable and none of them experienced chronic thromboembolic pulmonary hypertension. CONCLUSIONS Ninety-day survival and bleeding events rates did not differ in patients treated with VA-ECMO after systemic thrombolysis compared to those who were not. Recent systemic thrombolysis, as a single parameter, should not be considered as a contraindication for VA-ECMO in high-risk PE.
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Affiliation(s)
- David Levy
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Ouriel Saura
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Maria Teresa Passarelli
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Manuela Lucenteforte
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Guillaume Lebreton
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Adrien Bougle
- Department of Anesthesiology and Critical Care Medicine, Cardiology Institute, GRC 29, AP-HP, Pitié-Salpêtrière Hospital, Sorbonne University, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne University, Paris, France
- INSERM UMRS-959 Immunology-Immunopathology-Immunotherapy (I3), Sorbonne University, Paris, France
| | - Sofia Ortuno
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Yoël Benitha
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Nadjib Hammoudi
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- ACTION Study Group, Sorbonne Université, INSERM UMR_S 1166, Hôpital Pitié-Salpêtrière (AP-HP), Boulevard de L'Hôpital, 75013, Paris, France
| | - Benjamin Assouline
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Intensive Care Medicine Unit, Division of Intensive Care, Department of Acute Medicine, University Hospital of Geneva, Geneva, Switzerland
| | - Matthieu Petit
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Melchior Gautier
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Lucie Le Fevre
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Marc Pineton de Chambrun
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
- Service de Médecine Interne 2, Centre de Référence Lupus Systémique, SAPL et Autres Maladies Auto-Immunes et Systémiques Rares, AP-HP, Sorbonne Université, Hôpital de La Pitié-Salpêtrière, 75013, Paris, France
| | - Charles Juvin
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Juliette Chommeloux
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Charles-Edouard Luyt
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Guillaume Hékimian
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Pascal Leprince
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Chirurgie Cardiaque et Thoracique, Institut de Cardiologie, AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France
| | - Matthieu Schmidt
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France.
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Sorbonne Université, Hôpital Pitié-Salpêtrière, 47-83 Boulevard de L'Hôpital, 75013, Paris, France.
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Farmakis IT, Sagoschen I, Barco S, Keller K, Valerio L, Wild J, Giannakoulas G, Piazza G, Konstantinides SV, Hobohm L. Extracorporeal Membrane Oxygenation and Reperfusion Strategies in High-Risk Pulmonary Embolism Hospitalizations. Crit Care Med 2024:00003246-990000000-00347. [PMID: 38904439 DOI: 10.1097/ccm.0000000000006361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024]
Abstract
OBJECTIVES To investigate the contemporary use of extracorporeal membrane oxygenation (ECMO) in conjunction with reperfusion strategies in high-risk pulmonary embolism (PE). DESIGN Observational epidemiological analysis. SETTING The U.S. Nationwide Inpatient Sample (NIS) (years 2016-2020). PATIENTS High-risk PE hospitalizations. MEASUREMENTS AND MAIN RESULTS Use of ECMO in conjunction with thrombolysis-based reperfusion (systemic thrombolysis or catheter-directed thrombolysis) or mechanical reperfusion (surgical embolectomy or catheter-based thrombectomy) with regards to in-hospital mortality and major bleeding. We identified high-risk PE hospitalizations in the NIS (years 2016-2020) and investigated the use of ECMO in conjunction with thrombolysis-based (systemic thrombolysis or catheter-directed thrombolysis) and mechanical (surgical embolectomy or catheter-based thrombectomy) reperfusion strategies with regards to in-hospital mortality and major bleeding. Among 122,735 hospitalizations for high-risk PE, ECMO was used in 2,805 (2.3%); stand-alone in 1.4%, thrombolysis-based reperfusion in 0.4%, and mechanical reperfusion in 0.5%. Compared with neither reperfusion nor ECMO, ECMO plus thrombolysis-based reperfusion was associated with reduced in-hospital mortality (adjusted odds ratio [aOR] 0.61; 95% CI, 0.38-0.98), whereas no difference was found with ECMO plus mechanical reperfusion (aOR 1.03; 95% CI, 0.67-1.60), and ECMO stand-alone was associated with increased in-hospital mortality (aOR 1.60; 95% CI, 1.22-2.10). In the cardiac arrest subgroup, ECMO was associated with reduced in-hospital mortality (aOR 0.71; 95% CI, 0.53-0.93). Among all patients on ECMO, thrombolysis-based reperfusion was significantly associated (aOR 0.55; 95% CI, 0.33-0.91), and mechanical reperfusion showed a trend (aOR 0.75; 95% CI, 0.47-1.19) toward reduced in-hospital mortality compared with no reperfusion, without increases in major bleeding. CONCLUSIONS In patients with high-risk PE and refractory hemodynamic instability, ECMO may be a valuable supportive treatment in conjunction with reperfusion treatment but not as a stand-alone treatment especially for patients suffering from cardiac arrest.
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Affiliation(s)
- Ioannis T Farmakis
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Karsten Keller
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Baden-Wuerttemberg, Heidelberg, Germany
| | - Luca Valerio
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
| | - Johannes Wild
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
| | - George Giannakoulas
- Department of Cardiology, AHEPA University General Hospital of Thessaloniki, Aristotle University of Thessaloniki, Makedonia, Thessaloniki, Greece
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Greece
| | - Lukas Hobohm
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
- Department of Cardiology, University Medical Center of the Johannes Gutenberg University, Rhineland Palatinate, Mainz, Germany
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Glazier HA, Kaki A. Role of Extracorporeal Membrane Oxygenation in the Treatment of Massive Pulmonary Embolism. Int J Angiol 2024; 33:107-111. [PMID: 38846997 PMCID: PMC11152616 DOI: 10.1055/s-0044-1782658] [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: 06/09/2024] Open
Abstract
Massive/high-risk pulmonary embolism (PE) is associated with a 30-day mortality rate of approximately 65%. In searching for strategies that may make a dent on this dismal mortality rate, investigators have, over the last decade, shown renewed interest in the potential beneficial role of venoarterial (V-A) extracorporeal membrane oxygenation (ECMO) in the treatment of patients with high-risk PE. There is a dearth of high-quality evidence regarding the value of ECMO in the treatment of massive PE. Studies examining this issue have generally been retrospective, often single center and frequently with small patient numbers. Moreover, these reported studies are not matched with appropriate controls, and, accordingly, it is difficult to regulate for inherent treatment bias. Not surprisingly, there are no randomized controlled trials examining the value of ECMO in the treatment of massive PE, as such trials would pose formidable feasibility challenges. Over the past several years, there has been increasing support for upfront use of V-A ECMO in the treatment of massive PE, when it is complicated by cardiac arrest. In those patients without cardiac arrest, but who have contraindications for thrombolysis, V-A ECMO combined with anticoagulation may be used to stabilize the patient. If after 3 to 5 days, such patients demonstrate persistent right ventricular dysfunction, embolectomy (either surgical or catheter based) should be performed. Well-designed, multicenter, prospective studies are urgently needed to better define the role of V-A ECMO in the treatment of patients with massive PE.
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Affiliation(s)
- Hugh A. Glazier
- Department of Surgery, University Hospital Galway, Galway, Ireland
| | - Amir Kaki
- Division of Cardiology, St. John University Hospital, Detroit, Michigan
- Department of Medicine, Wayne State University, Detroit, Michigan
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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024; 44:182-192. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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9
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [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: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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10
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Makowska A, Treumann T, Venturini S, Christ M. Pulmonary Embolism in Pregnancy: A Review for Clinical Practitioners. J Clin Med 2024; 13:2863. [PMID: 38792409 PMCID: PMC11121909 DOI: 10.3390/jcm13102863] [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: 03/26/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024] Open
Abstract
Diagnostic and therapeutic decision-making in pregnancy with suspected pulmonary embolism (PE) is challenging. European and other international professional societies have proposed various recommendations that are ambiguous, probably due to the unavailability of randomized controlled trials. In the following sections, we discuss the supporting diagnostic steps and treatments. We suggest a standardized diagnostic work-up in pregnant patients presenting with symptoms of PE to make evidence-based diagnostic and therapeutic decisions. We strongly recommend that clinical decisions on treatment in pregnant patients with intermediate- or high-risk pulmonary embolism should include a multidisciplinary team approach involving emergency physicians, pulmonologists, angiologist, cardiologists, thoracic and/or cardiovascular surgeons, radiologists, and obstetricians to choose a tailored management option including an interventional treatment. It is important to be aware of the differences among guidelines and to assess each case individually, considering the specific views of the different specialties. This review summarizes key concepts of the diagnostics and acute management of pregnant women with suspected PE that are supportive for the clinician on duty.
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Affiliation(s)
- Agata Makowska
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
- Cardiology, Hospital Centre of Biel, 2501 Biel, Switzerland
| | - Thomas Treumann
- Radiology, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland;
| | - Stefan Venturini
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
| | - Michael Christ
- Emergency Department, Cantonal Hospital Lucerne, 6000 Lucerne, Switzerland; (S.V.); (M.C.)
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11
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Cardona S, Downing JV, Witting MD, Haase DJ, Powell EK, Dahi S, Pasrija C, Tran QK. Venoarterial Extracorporeal Membrane Oxygenation With or Without Advanced Intervention for Massive Pulmonary Embolism. Perfusion 2024; 39:665-674. [PMID: 37246150 DOI: 10.1177/02676591231177909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study's objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010-2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests. RESULTS We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9-3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications. CONCLUSION Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Jessica V Downing
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth K Powell
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Quincy K Tran
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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12
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Sagoschen I, Scibior B, Farmakis IT, Keller K, Graafen D, Griemert EV, Vosseler M, Treede H, Münzel T, Knorr M, Gori T, Konstantinides S, Hobohm L. A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany. Clin Res Cardiol 2024; 113:581-590. [PMID: 38112742 PMCID: PMC10954947 DOI: 10.1007/s00392-023-02364-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 12/07/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE). PURPOSE To investigate PERT's composition and added clinical value in a university center in Germany. METHODS Over 4 years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality. RESULTS From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121). CONCLUSION PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.
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Affiliation(s)
- Ingo Sagoschen
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Barbara Scibior
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Graafen
- Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Markus Vosseler
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Hendrik Treede
- Department for Cardiac and Vascular Surgery, University Medical Center Mainz of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maike Knorr
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany.
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13
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Ali S, Meuwese CL, Moors XJR, Donker DW, van de Koolwijk AF, van de Poll MCG, Gommers D, Dos Reis Miranda D. Extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest: an overview of current practice and evidence. Neth Heart J 2024; 32:148-155. [PMID: 38376712 PMCID: PMC10951133 DOI: 10.1007/s12471-023-01853-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/21/2024] Open
Abstract
Cardiac arrest (CA) is a common and potentially avoidable cause of death, while constituting a substantial public health burden. Although survival rates for out-of-hospital cardiac arrest (OHCA) have improved in recent decades, the prognosis for refractory OHCA remains poor. The use of veno-arterial extracorporeal membrane oxygenation during cardiopulmonary resuscitation (ECPR) is increasingly being considered to support rescue measures when conventional cardiopulmonary resuscitation (CPR) fails. ECPR enables immediate haemodynamic and respiratory stabilisation of patients with CA who are refractory to conventional CPR and thereby reduces the low-flow time, promoting favourable neurological outcomes. In the case of refractory OHCA, multiple studies have shown beneficial effects in specific patient categories. However, ECPR might be more effective if it is implemented in the pre-hospital setting to reduce the low-flow time, thereby limiting permanent brain damage. The ongoing ON-SCENE trial might provide a definitive answer regarding the effectiveness of ECPR. The aim of this narrative review is to present the most recent literature available on ECPR and its current developments.
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Affiliation(s)
- Samir Ali
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands.
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands.
- Ministry of Defence, Royal Netherlands Air Force, Breda, The Netherlands.
| | - Christiaan L Meuwese
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Xavier J R Moors
- Department of Anaesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Dirk W Donker
- Cardiovascular and Respiratory Physiology, Faculty of Science and Technology, University of Twente, Enschede, The Netherlands
- Department of Intensive Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Anina F van de Koolwijk
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Diederik Gommers
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Centre, Rotterdam, The Netherlands
- Helicopter Emergency Medical Services, Trauma Centre Zuid-West Nederland, Erasmus University Medical Centre, Rotterdam, The Netherlands
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14
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Finocchiaro S, Mauro MS, Rochira C, Spagnolo M, Laudani C, Landolina D, Mazzone PM, Agnello F, Ammirabile N, Faro DC, Imbesi A, Occhipinti G, Greco A, Capodanno D. Percutaneous interventions for pulmonary embolism. EUROINTERVENTION 2024; 20:e408-e424. [PMID: 38562073 PMCID: PMC10979388 DOI: 10.4244/eij-d-23-00895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/19/2024] [Indexed: 04/04/2024]
Abstract
Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.
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Affiliation(s)
- Simone Finocchiaro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Maria Sara Mauro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Carla Rochira
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Marco Spagnolo
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Claudio Laudani
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Landolina
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Placido Maria Mazzone
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Federica Agnello
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Nicola Ammirabile
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Denise Cristiana Faro
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonino Imbesi
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Giovanni Occhipinti
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Antonio Greco
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
| | - Davide Capodanno
- Division of Cardiology, Azienda Ospedaliero-Universitaria Policlinico "G. Rodolico - San Marco", University of Catania, Catania, Italy
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15
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Falsetti L, Guerrieri E, Zaccone V, Viticchi G, Santini S, Giovenali L, Lagonigro G, Carletti S, Gialluca Palma LE, Tarquinio N, Moroncini G. Cutting-Edge Techniques and Drugs for the Treatment of Pulmonary Embolism: Current Knowledge and Future Perspectives. J Clin Med 2024; 13:1952. [PMID: 38610717 PMCID: PMC11012374 DOI: 10.3390/jcm13071952] [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: 02/20/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and treatment. Recent advances have led to the development of newer techniques and drugs aimed at improving PE management, reducing its associated morbidity and mortality and the complications related to anticoagulation. This review provides an overview of the current knowledge and future perspectives on PE treatment. Anticoagulation represents the first-line treatment of hemodynamically stable PE, direct oral anticoagulants being a safe and effective alternative to traditional anticoagulation: these drugs have a rapid onset of action, predictable pharmacokinetics, and low bleeding risk. Systemic fibrinolysis is suggested in patients with cardiac arrest, refractory hypotension, or shock due to PE. With this narrative review, we aim to assess the state of the art of newer techniques and drugs that could radically improve PE management in the near future: (i) mechanical thrombectomy and pulmonary embolectomy are promising techniques reserved to patients with massive PE and contraindications or failure to systemic thrombolysis; (ii) catheter-directed thrombolysis is a minimally invasive approach that can be suggested for the treatment of massive or submassive PE, but the lack of large, randomized controlled trials represents a limitation to widespread use; (iii) novel pharmacological approaches, by agents inhibiting thrombin-activatable fibrinolysis inhibitor, factor Xia, and the complement cascade, are currently under investigation to improve PE-related outcomes in specific settings.
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Affiliation(s)
- Lorenzo Falsetti
- Clinica Medica, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.F.)
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Vincenzo Zaccone
- Internal and Subintensive Medicine, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanna Viticchi
- Clinica di Neurologia, Dipartimento Scienze Cliniche e Molecolare, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Silvia Santini
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Laura Giovenali
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Graziana Lagonigro
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Stella Carletti
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | | | - Nicola Tarquinio
- Internal Medicine Department, INRCA-IRCCS Osimo-Ancona, 60027 Ancona, Italy
| | - Gianluca Moroncini
- Clinica Medica, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.F.)
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16
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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17
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Nikolovski SS, Lazic AD, Fiser ZZ, Obradovic IA, Tijanic JZ, Raffay V. Recovery and Survival of Patients After Out-of-Hospital Cardiac Arrest: A Literature Review Showcasing the Big Picture of Intensive Care Unit-Related Factors. Cureus 2024; 16:e54827. [PMID: 38529434 PMCID: PMC10962929 DOI: 10.7759/cureus.54827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2024] [Indexed: 03/27/2024] Open
Abstract
As an important public health issue, out-of-hospital cardiac arrest (OHCA) requires several stages of high quality medical care, both on-field and after hospital admission. Post-cardiac arrest shock can lead to severe neurological injury, resulting in poor recovery outcome and increased risk of death. These characteristics make this condition one of the most important issues to deal with in post-OHCA patients hospitalized in intensive care units (ICUs). Also, the majority of initial post-resuscitation survivors have underlying coronary diseases making revascularization procedure another crucial step in early management of these patients. Besides keeping myocardial blood flow at a satisfactory level, other tissues must not be neglected as well, and maintaining mean arterial pressure within optimal range is also preferable. All these procedures can be simplified to a certain level along with using targeted temperature management methods in order to decrease metabolic demands in ICU-hospitalized post-OHCA patients. Additionally, withdrawal of life-sustaining therapy as a controversial ethical topic is under constant re-evaluation due to its possible influence on overall mortality rates in patients initially surviving OHCA. Focusing on all of these important points in process of managing ICU patients is an imperative towards better survival and complete recovery rates.
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Affiliation(s)
- Srdjan S Nikolovski
- Pathology and Laboratory Medicine, Cardiovascular Research Institute, Loyola University Chicago Health Science Campus, Maywood, USA
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Aleksandra D Lazic
- Emergency Center, Clinical Center of Vojvodina, Novi Sad, SRB
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
| | - Zoran Z Fiser
- Emergency Medicine, Department of Emergency Medicine, Novi Sad, SRB
| | - Ivana A Obradovic
- Anesthesiology, Resuscitation, and Intensive Care, Sveti Vračevi Hospital, Bijeljina, BIH
| | - Jelena Z Tijanic
- Emergency Medicine, Municipal Institute of Emergency Medicine, Kragujevac, SRB
| | - Violetta Raffay
- School of Medicine, European University Cyprus, Nicosia, CYP
- Emergency Medicine, Serbian Resuscitation Council, Novi Sad, SRB
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18
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Bashir DA, Cargill JC, Gowda S, Musick M, Coleman R, Chartan CA, Hensch L, Pezeshkmehr A, Qureshi AM, Sartain SE. Implementing a Pediatric Pulmonary Embolism Response Team Model: An Institutional Experience. Chest 2024; 165:192-201. [PMID: 38199732 DOI: 10.1016/j.chest.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 07/21/2023] [Accepted: 07/24/2023] [Indexed: 01/12/2024] Open
Abstract
Pulmonary embolism is increasing in prevalence among pediatric patients; although still rare, it can create a significant risk for morbidity and death within the pediatric patient population. Pulmonary embolism presents in various ways depending on the patient, the size of the embolism, and the comorbidities. Treatment decisions are often driven by the severity of the presentation and hemodynamic effects; severe presentations require more invasive and aggressive treatment. We describe the development and implementation of a pediatric pulmonary embolism response team designed to facilitate rapid, multidisciplinary, data-driven treatment decisions and management.
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Affiliation(s)
- Dalia A Bashir
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX.
| | - Jamie C Cargill
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Srinath Gowda
- Division of Cardiology- Interventional Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Matthew Musick
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Ryan Coleman
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Corey A Chartan
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Lisa Hensch
- Department of Pathology & Immunology and Anesthesia, Division of Transfusion Medicine & Coagulation, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Amir Pezeshkmehr
- Department of Radiology, Division of Interventional Radiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Athar M Qureshi
- Division of Cardiology- Interventional Cardiology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Sarah E Sartain
- Division of Hematology, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
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19
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Boey JJE, Dhundi U, Ling RR, Chiew JK, Fong NCJ, Chen Y, Hobohm L, Nair P, Lorusso R, MacLaren G, Ramanathan K. Extracorporeal Membrane Oxygenation for Pulmonary Embolism: A Systematic Review and Meta-Analysis. J Clin Med 2023; 13:64. [PMID: 38202071 PMCID: PMC10779708 DOI: 10.3390/jcm13010064] [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: 10/30/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) for high-risk pulmonary embolism (HRPE) with haemodynamic instability or profound cardiogenic shock has been reported. Guidelines currently support the use of ECMO only in patients with cardiac arrest or circulatory collapse and in conjunction with other curative therapies. We aimed to characterise the mortality of adults with HRPE treated with ECMO, identify factors associated with mortality, and compare different adjunct curative therapies. METHODS We conducted a systematic review and meta-analysis, searching four international databases from their inception until 25 June 2023 for studies reporting on more than five patients receiving ECMO for HRPE. Random-effects meta-analyses were conducted. The primary outcome was in-hospital mortality. A subgroup analysis investigating the outcomes with curative treatment for HRPE was also performed. The intra-study risk of bias and the certainty of evidence were also assessed. This study was registered with PROSPERO (CRD42022297518). RESULTS A total of 39 observational studies involving 6409 patients receiving ECMO for HRPE were included in the meta-analysis. The pooled mortality was 42.8% (95% confidence interval [CI]: 37.2% to 48.7%, moderate certainty). Patients treated with ECMO and catheter-directed therapy (28.6%) had significantly lower mortality (p < 0.0001) compared to those treated with ECMO and systemic thrombolysis (57.0%). Cardiac arrest prior to ECMO initiation (regression coefficient [B]: 1.77, 95%-CI: 0.29 to 3.25, p = 0.018) and pre-ECMO heart rate (B: -0.076, 95%-CI: -0.12 to 0.035, p = 0.0003) were significantly associated with mortality. The pooled risk ratio when comparing mortality between patients on ECMO and those not on ECMO was 1.51 (95%-CI: 1.07 to 2.14, p < 0.01) in favour of ECMO. The pooled mortality was 55.2% (95%-CI: 47.7% to 62.6%), using trim-and-fill analysis to account for the significant publication bias. CONCLUSIONS More than 50% of patients receiving ECMO for HRPE survive. While outcomes may vary based on the curative therapy used, early ECMO should be considered as a stabilising measure when treating patients with HRPE. Patients treated concurrently with systemic thrombolysis have higher mortality than those receiving ECMO alone or with other curative therapies, particularly catheter-directed therapies. Further studies are required to explore ECMO vs. non-ECMO therapies in view of currently heterogenous datasets.
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Affiliation(s)
- Jonathan Jia En Boey
- Faculty of Medicine, University of New South Wales, Sydney, NSW 2052, Australia
- South Western Sydney Clinical Campuses, University of New South Wales, Sydney, NSW 2170, Australia
| | - Ujwal Dhundi
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119074, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119228, Singapore
| | - John Keong Chiew
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119228, Singapore
| | - Nicole Chui-Jiet Fong
- Royal College of Surgeons in Ireland (RCSI), University College Dublin (UCD) Malaysia Campus, D02 YN77 Dublin, Ireland
| | - Ying Chen
- Agency for Science, Technology and Research (A*STaR), Singapore 138632, Singapore
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I and Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, 55131 Mainz, Germany
| | - Priya Nair
- Department of Intensive Care, St. Vincent’s Hospital Sydney, Darlinghurst, NSW 2010, Australia
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, 6229 ER Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119228, Singapore
| | - Kollengode Ramanathan
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119074, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore 119228, Singapore
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20
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Khosla A, Zhao Y, Mojibian H, Pollak J, Singh I. High-Risk Pulmonary Embolism: Management for the Intensivist. J Intensive Care Med 2023; 38:1087-1098. [PMID: 37455352 DOI: 10.1177/08850666231188290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
High-risk pulmonary embolism (PE) also known as massive PE carries a high rate of morbidity and mortality. The incidence of high-risk PE continues to increase, yet the outcomes of high-risk PE continue to remain poor. Patients with high-risk PE are often critically ill, with complex underlying physiology, and treatment for the high-risk PE patient almost always requires care and management from an intensivist. Treatment options for high-risk PE continue to evolve rapidly with multiple options for definitive reperfusion therapy and supportive care. A thorough understanding of the physiology, risk stratification, treatment, and support options for the high-risk PE patient is necessary for all intensivists in order to improve outcomes. This article aims to provide a review from an intensivist's perspective highlighting the physiological consequences, risk stratification, and treatment options for these patients as well as providing a proposed algorithm to the risk stratification and acute management of high-risk PE.
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Affiliation(s)
- Akhil Khosla
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Yiyu Zhao
- Department of Anesthesia, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, USA
| | - Inderjit Singh
- Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, Yale New Haven Hospital, New Haven, CT, USA
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21
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Rivers J, Pilcher D, Kim J, Bartos JA, Burrell A. Extracorporeal membrane oxygenation for the treatment of massive pulmonary embolism. An analysis of the ELSO database. Resuscitation 2023; 191:109940. [PMID: 37625576 DOI: 10.1016/j.resuscitation.2023.109940] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023]
Abstract
AIM Extracorporeal membrane oxygenation (ECMO) may be beneficial in treatment of massive pulmonary embolus (PE), however the current evidence to guide its use is limited. We aimed to compare the incidence, characteristics, treatments, and outcomes of patients with massive PE by mode of ECMO from a large international registry. METHODS Retrospective observational study of the Extracorporeal Life Support Organization (ELSO) database. RESULTS A total of 821 patients underwent 833 ECMO episodes for PE. Mean age was 49 (±15) years, 408 (50.1%) were female, and 450 (54.7%) had a cardiac arrest prior to ECMO initiation. Venoarterial (VA) ECMO was the most common mode in 489 (58.7%), followed by extracorporeal cardiopulmonary resuscitation (ECPR) in 229 (27.4%) and venovenous (VV) ECMO in 85 (10.2%). The number of episodes per year increased over the study period, predominantly driven by an increase in ECPR. In-hospital mortality was the highest for ECPR 156/229 (68.1%), followed by VA ECMO 209/498 (42.7%) and VV ECMO 24/85 (28.2%) P < 0.001. After controlling for univariate and clinically significant variables at the time of ECMO initiation, increasing age (OR 1.02 (1.00-1.03), lower pH (OR 0.18 (0.03-0.44), lower diastolic blood pressure (OR 0.99 (0.97-1.00) and ECPR mode (OR 3.67 (1.46-9.230) were independently associated with in-hospital mortality. CONCLUSION ECMO use for massive PE is increasing globally, and overall mortality rates compare favorably with other indications of ECMO. The use of ECPR and worsening metabolic status at initiation were associated with higher in-hospital mortality, suggesting delays in initiating ECMO should be avoided.
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Affiliation(s)
- Jon Rivers
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - John Kim
- Heart Institute, Section of Cardiology, Department of Paediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jason A Bartos
- Division of Cardiology, Department of Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Aidan Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
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22
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Sakuraya M, Hifumi T, Inoue A, Sakamoto T, Kuroda Y. Neurological outcomes and reperfusion strategies in out-of-hospital cardiac arrest patients due to pulmonary embolism who underwent venoarterial extracorporeal membrane oxygenation: A post-hoc analysis of a multicenter retrospective cohort study. Resuscitation 2023; 191:109926. [PMID: 37544497 DOI: 10.1016/j.resuscitation.2023.109926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/28/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION This study aimed to evaluate the effect of different reperfusion strategies on neurological outcomes in patients with pulmonary embolism who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for out-of-hospital cardiac arrest (OHCA). METHODS This was a post-hoc analysis of a multicenter retrospective cohort study conducted in 36 institutions in Japan over six years. We included patients who underwent VA-ECMO and were diagnosed with pulmonary embolism caused by OHCA. Neurological outcomes were evaluated on the basis of the cerebral performance category at hospital discharge. We also assessed the association between reperfusion strategies and successful separation from ECMO. RESULTS Among the 78 included patients, approximately half were successfully weaned from ECMO. Hospital mortality and favorable neurological outcomes at hospital discharge were 60.3% and 17.9%, respectively. Thirty-one patients (39.7%) underwent reperfusion strategies after ECMO, including 13 who received systemic thrombolytic therapy and 18 who underwent mechanical reperfusion strategy. After adjusting for prespecified covariates using the competing risk model, reperfusion strategies increased ECMO separation rate (systemic thrombolytic therapy: subdistribution hazard ratio [sHR] 2.24, 95% confidence interval [CI] 1.21-4.17, P = 0.011; mechanical reperfusion strategy: sHR 1.70, 95% CI 0.86-3.41, P = 0.129) compared with anticoagulation therapy alone, whereas higher cardiac Sequential Organ Failure Assessment score decreased ECMO separation rate (sHR 0.81, 95% CI 0.67-0.97, P = 0.020). CONCLUSIONS Favorable neurological outcomes were observed in less than 20% of patients with OHCA due to pulmonary embolism undergoing ECMO. Reperfusion strategies may be associated with shorter ECMO durations in these patients. CLINICAL TRIAL REGISTRATION https://center6.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000041577 (unique identifier: UMIN000036490).
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Affiliation(s)
- Masaaki Sakuraya
- JA Hiroshima General Hospital, Department of Emergency and Intensive Care Medicine, Jigozen 1-3-3, Hatsukaichi, Hiroshima 738-8503, Japan; Shiga University, Graduate School of Data Science, 1-1-1 Banba, Hikone, Shiga 522-8522, Japan.
| | - Toru Hifumi
- St. Luke's International Hospital, Department of Emergency and Critical Care Medicine, 9-1 Akashi-cho, Chuo-ku, Tokyo 104-8560, Japan.
| | - Akihiko Inoue
- Hyogo Emergency Medical Center, Department of Emergency and Critical Care Medicine, 1-3-1 Wakinohamakaigandori, Chuo-ku, Kobe, Hyogo 651-0073, Japan.
| | - Tetsuya Sakamoto
- Teikyo University School of Medicine, Department of Emergency Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan.
| | - Yasuhiro Kuroda
- Kagawa University Hospital, Department of Emergency, Disaster and Critical Care Medicine, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa 761-0793, Japan.
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23
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Pudil J, Rob D, Smalcova J, Smid O, Huptych M, Vesela M, Kovarnik T, Belohlavek J. Pulmonary embolism-related refractory out-of-hospital cardiac arrest and extracorporeal cardiopulmonary resuscitation: Prague OHCA study post hoc analysis. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:507-512. [PMID: 37172033 PMCID: PMC10449371 DOI: 10.1093/ehjacc/zuad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/02/2023] [Accepted: 05/11/2023] [Indexed: 05/14/2023]
Abstract
AIMS Refractory out-of-hospital cardiac arrest (r-OHCA) in patients with pulmonary embolism (PE) is associated with poor outcomes. The role of extracorporeal cardiopulmonary resuscitation (ECPR) in this patient group is uncertain. This study aims to analyse clinical course, outcomes, and the effect of an invasive procedure, including ECPR, in a randomized population. METHODS AND RESULTS A post hoc analysis of a randomized controlled trial (Prague OHCA study) was conducted to evaluate the effect of ECPR vs. a standard approach in r-OHCA. A subgroup of patients with PE-related r-OHCA was identified, and procedural and outcome characteristics, including favourable neurological survival, organ donation, and complications, were compared to patients without PE. Pulmonary embolism was identified as a cause of r-OHCA in 24 of 256 (9.4%) enrolled patients. Patients with PE were more likely to be women [12/24 (50%) vs. 32/232 (13.8%); P < 0.001] and presented more frequently with an initial non-shockable rhythm [23/24 (95.8%) vs. 77/232 (33.2%); P < 0.001], as well as more severe acidosis at admission [median pH (interquartile range); 6.83 (6.75-6.88) vs. 6.98 (6.82-7.14); P < 0.001]. Their favourable 180-day neurological survival was significantly lower [2/24 (8.3%) vs. 66/232 (28.4%); P = 0.049], but the proportion of accepted organ donors was higher (16.7 vs. 4.7%, P = 0.04). CONCLUSION Refractory out-of-hospital cardiac arrest due to PE has a different presentation and inferior outcomes compared to other causes but may represent an important source of organ donations. The ECPR method did not improve patient outcomes.
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Affiliation(s)
- Jan Pudil
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
| | - Daniel Rob
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
| | - Jan Smalcova
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
- Emergency Medical Service, Prague, Czech Republic
| | - Ondrej Smid
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
| | - Michal Huptych
- Czech Institute of Informatics, Robotics and Cybernetics (CIIRC), Czech Technical University, Prague, Czech Republic
| | - Michaela Vesela
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
| | - Tomas Kovarnik
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
| | - Jan Belohlavek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital, U Nemocnice 2, Prague 128 00, Czech Republic
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Qiu MS, Deng YJ, Yang X, Shao HQ. Cardiac arrest secondary to pulmonary embolism treated with extracorporeal cardiopulmonary resuscitation: Six case reports. World J Clin Cases 2023; 11:4098-4104. [PMID: 37388806 PMCID: PMC10303601 DOI: 10.12998/wjcc.v11.i17.4098] [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: 03/10/2023] [Revised: 04/30/2023] [Accepted: 05/22/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Massive pulmonary embolism (PE) results in extremely high mortality rates. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can provide circulatory and oxygenation support and rescue patients with massive PE. However, there are relatively few studies of extracorporeal cardiopulmonary resuscitation (ECPR) in patients with cardiac arrest (CA) secondary to PE. The aim of the present study is to investigate the clinical use of ECPR in conjunction with heparin anticoagulation in patients with CA secondary to PE.
CASE SUMMARY We report the cases of six patients with CA secondary to PE treated with ECPR in the intensive care unit of our hospital between June 2020 and June 2022. All six patients experienced witnessed CA whilst in hospital. They had acute onset of severe respiratory distress, hypoxia, and shock rapidly followed by CA and were immediately given cardiopulmonary resuscitation and adjunctive VA-ECMO therapy. During hospitalization, pulmonary artery computed tomography angiography was performed to confirm the diagnosis of PE. Through anticoagulation management, mechanical ventilation, fluid management, and antibiotic treatment, five patients were successfully weaned from ECMO (83.33%), four patients survived for 30 d after discharge (66.67%), and two patients had good neurological outcomes (33.33%).
CONCLUSION For patients with CA secondary to massive PE, ECPR in conjunction with heparin anticoagulation may improve outcomes.
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Affiliation(s)
- Min-Shan Qiu
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Yong-Jin Deng
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Xue Yang
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
| | - Han-Quan Shao
- Department of Critical Care Medicine, Dongguan People’s Hospital, Dongguan 523058, Guangdong Province, China
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25
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Nishimoto Y, Ohbe H, Matsui H, Nakajima M, Sasabuchi Y, Sato Y, Watanabe T, Yamada T, Fukunami M, Yasunaga H. Trends in Treatment Patterns and Outcomes of Patients With Pulmonary Embolism in Japan, 2010 to 2020: A Nationwide Inpatient Database Study. J Am Heart Assoc 2023:e028981. [PMID: 37301745 DOI: 10.1161/jaha.122.028981] [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] [Received: 02/21/2023] [Accepted: 05/01/2023] [Indexed: 06/12/2023]
Abstract
Background The impact of major changes in the treatment practice of pulmonary embolism (PE), such as limited indications for systemic thrombolysis and the introduction of direct oral anticoagulants, is not well documented. This study aimed to describe annual trends in the treatment patterns and outcomes in patients with PE. Methods and Results Using the Japanese Diagnosis Procedure Combination inpatient database from April 2010 to March 2021, we identified hospitalized patients with PE. Patients with high-risk PE were defined as those admitted for out-of-hospital cardiac arrest or who received cardiopulmonary resuscitation, extracorporeal membrane oxygenation, vasopressors, or invasive mechanical ventilation on the day of admission. The remaining patients were defined as patients with non-high-risk PE. The patient characteristics and outcomes were reported with fiscal year trend analyses. Of 88 966 eligible patients, 8116 (9.1%) had high-risk PE, and the remaining 80 850 (90.9%) had non-high-risk PE. Between 2010 and 2020, in patients with high-risk PE, the annual proportion of extracorporeal membrane oxygenation use significantly increased from 11.0% to 21.3%, whereas that of thrombolysis use significantly decreased from 22.5% to 15.5% (P for trend <0.001 for both). In-hospital mortality significantly decreased from 51.0% to 43.7% (P for trend=0.04). In patients with non-high-risk PE, the annual proportion of direct oral anticoagulant use increased from 0.0% to 38.3%, whereas that of thrombolysis use significantly decreased from 13.7% to 3.4% (P for trend <0.001 for both). In-hospital mortality significantly decreased from 7.9% to 5.4% (P for trend <0.001). Conclusions Substantial changes in the PE practice and outcomes occurred in patients with high-risk and non-high-risk PE.
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Affiliation(s)
- Yuji Nishimoto
- Division of Cardiology, Osaka General Medical Center Osaka Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health The University of Tokyo Tokyo Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health The University of Tokyo Tokyo Japan
| | - Mikio Nakajima
- Department of Clinical Epidemiology and Health Economics, School of Public Health The University of Tokyo Tokyo Japan
- Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development Tokyo Japan
| | | | - Yukihito Sato
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center Amagasaki Japan
| | - Tetsuya Watanabe
- Division of Cardiology, Osaka General Medical Center Osaka Japan
| | - Takahisa Yamada
- Division of Cardiology, Osaka General Medical Center Osaka Japan
| | | | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health The University of Tokyo Tokyo Japan
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Kelty CE, Berjaoui W, Shrestha NK, Fitch S, Jovinge SM, Rendon RL. Veno-arterial extracorporeal membrane oxygenation versus standard medical management for massive pulmonary embolism. Perfusion 2023:2676591231182247. [PMID: 37283140 DOI: 10.1177/02676591231182247] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
PURPOSE There is limited research on the use and outcomes of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) treatment for massive pulmonary embolism (PE). This study compared VA-ECMO treatment for massive PE versus patients treated medically. MATERIALS AND METHODS Patients diagnosed with massive PE at one hospital system were reviewed. VA-ECMO and non-ECMO groups were compared by t test and Chi-square. Mortality risk factors were identified by logistic regression. Survival was assessed by Kaplan Meier and propensity matching of groups. RESULTS Ninety-two patients were included (22 VA-ECMO and 70 non-ECMO). Age (OR 1.08, 95% CI 1.03-1.13), arterial SBP (OR 0.97, 95% CI 0.94-0.99), albumin (OR 0.3, 95% CI 0.1-0.8), and phosphorus (OR 2.0, 95% CI 1.4-3.17) were independently associated with 30-day mortality. Alkaline phosphate (OR 1.03, 95% CI 1.01-1.05) and SOFA score (OR 1.3, 95% CI 1.06-1.51) were associated with 1-year mortality. Propensity matching showed no difference in 30-day (59% VA-ECMO versus 72% non-ECMO, p = 0.363) or 1-year survival (50% VA-ECMO versus 64% non-ECMO, p = 0.355). CONCLUSIONS Patients treated with VA-ECMO for massive PE and medically treated patients have similar short- and long-term survival. Further research is needed to define clinical recommendations and benefits of intensive therapy such as VA-ECMO in this critically ill population.
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Affiliation(s)
- Catherine E Kelty
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Wael Berjaoui
- Pulmonary Medicine, Spectrum Health, Grand Rapids, MI, USA
| | - Nabin K Shrestha
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
| | - Stephen Fitch
- Pulmonary Medicine, Spectrum Health, Grand Rapids, MI, USA
| | - Stefan M Jovinge
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
- Cardiovascular Institute, Stanford University, Stanford, CA, USA
| | - Renzo Loyaga Rendon
- Frederik Meijer Heart and Vascular Institute, Spectrum Health, Grand Rapids, MI, USA
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Hobohm L, Keller K, Konstantinides S. [Pulmonary embolism]. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023; 37:133-142. [PMID: 37284023 PMCID: PMC10160724 DOI: 10.1007/s00398-023-00582-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Pulmonary embolism is a frequent cardiovascular disease which in recent years has shown a reduction in the mortality but an increase in the incidence. Due to the optimization of clinical probability scores and the interpretation of the D‑dimer test, unnecessary examinations using computed tomography with respect to the exclusion of an acute pulmonary embolism can be avoided, also in pregnant women. The evaluation of the right ventricle contributes to a risk-adapted treatment. Treatment consists of anticoagulation, alone or in combination with reperfusion treatment, such as systemic thrombolysis and also catheter-assisted or surgical treatment. In addition to acute treatment of pulmonary embolisms, an adequate aftercare is important, particularly for the early detection of long-term sequelae. This review article summarizes the current recommendations of international guidelines for patients with pulmonary embolism, accompanied by clinical case examples and a critical discussion.
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Affiliation(s)
- Lukas Hobohm
- Centrum für Thrombose und Hämostase, Universitätsmedizin Mainz, Mainz, Deutschland
- Kardiologie I, Zentrum für Kardiologie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Deutschland
| | - Karsten Keller
- Centrum für Thrombose und Hämostase, Universitätsmedizin Mainz, Mainz, Deutschland
- Kardiologie I, Zentrum für Kardiologie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131 Mainz, Deutschland
- Innere Medizin VII, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Helms J, Carrier M, Klok FA. High-risk pulmonary embolism in the intensive care unit. Intensive Care Med 2023; 49:579-582. [PMID: 36929423 DOI: 10.1007/s00134-023-07011-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 02/16/2023] [Indexed: 03/18/2023]
Affiliation(s)
- Julie Helms
- Faculté de Médecine, Service de Médecine Intensive-Réanimation, Université de Strasbourg (UNISTRA), Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, 1, Place de L'Hôpital, Strasbourg, France.
| | - Marc Carrier
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Canada
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Danial P, Olivier ME, Bréchot N, Ponnaiah M, Schoell T, D'Alessandro C, Demondion P, Clément M, Juvin C, Carillion A, Bouglé A, Combes A, Leprince P, Lebreton G. Association Between Shock Etiology and 5-Year Outcomes After Venoarterial Extracorporeal Membrane Oxygenation. J Am Coll Cardiol 2023; 81:897-909. [PMID: 36858709 DOI: 10.1016/j.jacc.2022.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/17/2022] [Accepted: 12/02/2022] [Indexed: 03/02/2023]
Abstract
BACKGROUND Outcomes of patients requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO) vary greatly by etiology, but large studies that incorporate the spectrum of shock supported with ECMO are rare. OBJECTIVES The purpose of this study was to describe the etiology-related outcome of patients with shock supported with peripheral VA-ECMO. METHODS All consecutive adults with peripheral VA-ECMO between January 2015 and August 2018 at Pitié-Salpêtrière Hospital (Paris, France) were included in this retrospective observational study. The indication for VA-ECMO was cardiogenic shock. Rates of hospital death and neurological, renal, and pulmonary complications were evaluated according to etiology. RESULTS Among 1,253 patients, hospital and 5-year survival rates were, respectively, 73.3% and 57.3% for primary graft failure, 58.6% and 54.0% for drug overdose, 53.2% and 45.3% for dilated cardiomyopathy, 51.6% and 50.0% for arrhythmic storm, 46.8% and 38.3% for massive pulmonary embolism, 44.4% and 42.4% for sepsis-induced cardiogenic shock, 37.9% and 32.9% for fulminant myocarditis, 37.3% and 31.5% for acute myocardial infarction, 34.6% and 33.3% for postcardiotomy excluding primary graft failure, 25.7% and 22.8% for other/unknown etiology, and 11.1% and 0.0% for refractory vasoplegia shock. Renal failure requiring hemodialysis developed in 50.0%, neurological complications in 16.0%, and hydrostatic pulmonary edema in 9.0%. CONCLUSIONS Although the outcome differs depending on etiology, this difference is related more to the severity of the situation associated with the cause rather than the cause of the shock per se. Survival to 5 years varied by cause, which may reflect the natural course of the chronic disease and illustrates the need for long-term follow-up.
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Affiliation(s)
- Pichoy Danial
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France.
| | - Maud-Emmanuel Olivier
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Nicolas Bréchot
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Maharajah Ponnaiah
- Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Thibaut Schoell
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Cosimo D'Alessandro
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Pierre Demondion
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Marina Clément
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Charles Juvin
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Aude Carillion
- Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Adrien Bouglé
- Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Medical Intensive Care Unit, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Sorbonne University, INSERM UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
| | - Guillaume Lebreton
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France; Department of Anaesthesiology and Surgical Intensive Care, Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris-Sorbonne University, Paris, France
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Abstract
BACKGROUND Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established. AREAS OF UNCERTAINTY Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions. THERAPEUTIC ADVANCES Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions. CONCLUSIONS There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.
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Goldberg JB, Giri J, Kobayashi T, Ruel M, Mittnacht AJC, Rivera-Lebron B, DeAnda A, Moriarty JM, MacGillivray TE. Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2023; 147:e628-e647. [PMID: 36688837 DOI: 10.1161/cir.0000000000001117] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.
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George TJ, Sheasby J, Sawhney R, DiMaio JM, Afzal A, Gable D, Sayfo S. Extracorporeal membrane oxygenation for large pulmonary emboli. Proc AMIA Symp 2023; 36:314-317. [PMID: 37091759 PMCID: PMC10120470 DOI: 10.1080/08998280.2023.2171699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Massive and submassive pulmonary emboli (PE) are increasingly being treated with percutaneous lytic and embolectomy procedures. While these procedures are overwhelmingly safe, patients with significant right ventricular strain are at risk for hemodynamic compromise requiring extracorporeal membrane oxygenation (ECMO). We conducted a retrospective study of all patients requiring ECMO support for PE from 2014 through 2022. The primary outcome was survival. Secondary outcomes included commonly encountered ECMO complications. From 2014 to 2022, 10 patients with submassive or massive PE required ECMO support. All 10 patients (100%) had right ventricular strain on echocardiography, 7 (70%) had a saddle PE, and 3 (30%) had extensive bilateral PE. Six (60%) patients required cardiopulmonary resuscitation prior to ECMO cannulation, and 4 (40%) were undergoing cardiopulmonary resuscitation while being cannulated. Nine (90%) patients were placed on venoarterial ECMO through the femoral vessels, while 1 (10%) was cannulated with right atrial to pulmonary artery ECMO. The median duration of support was 4 [3-8] days. During their course, 5 patients underwent percutaneous embolectomy, 1 underwent surgical embolectomy, and 4 underwent percutaneous lytic therapy. All patients (100%) survived to ECMO decannulation, and 6 (60%) survived to discharge. With a mean follow-up of 496 days, there were no postdischarge mortalities. In conclusion, although therapy for large PE is well tolerated, a small number of patients will experience periprocedural hemodynamic collapse requiring ECMO support. ECMO for PE patients is associated with acceptable morbidity and mortality. Further investigation is warranted to better characterize which patients are likely to require ECMO support.
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Affiliation(s)
- Timothy J. George
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Jenelle Sheasby
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Rahul Sawhney
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - J. Michael DiMaio
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Aasim Afzal
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Dennis Gable
- Vascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Sameh Sayfo
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
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Nishimoto Y, Ohbe H, Matsui H, Nakajima M, Sasabuchi Y, Sato Y, Watanabe T, Yamada T, Fukunami M, Yasunaga H. Effectiveness of systemic thrombolysis on clinical outcomes in high-risk pulmonary embolism patients with venoarterial extracorporeal membrane oxygenation: a nationwide inpatient database study. J Intensive Care 2023; 11:4. [PMID: 36740697 PMCID: PMC9901114 DOI: 10.1186/s40560-023-00651-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/24/2023] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Current guidelines recommend systemic thrombolysis as the first-line reperfusion treatment for patients with high-risk pulmonary embolism (PE) who present with cardiogenic shock but do not require venoarterial extracorporeal membrane oxygenation (VA-ECMO). However, little is known about the optimal reperfusion treatment in high-risk PE patients requiring VA-ECMO. We aimed to evaluate whether systemic thrombolysis improved high-risk PE patients' outcomes who received VA-ECMO. METHODS This was a retrospective cohort study using the Japanese Diagnosis Procedure Combination inpatient database from July 2010 to March 2021. We identified patients who were diagnosed with PE and received VA-ECMO on the day of admission. Patients who received systemic thrombolysis with monteplase or urokinase within two days of initiating VA-ECMO were defined as the thrombolysis group and the remaining patients as the control group. The primary outcome was in-hospital mortality and secondary outcomes were favorable neurological outcomes, length of hospital stay, VA-ECMO duration, total hospitalization cost, major bleeding, and blood transfusion volume. Propensity-score inverse probability of treatment weighting (IPTW) was performed to compare the outcomes between the groups. RESULTS Of 1220 eligible patients, 432 (35%) received systemic thrombolysis within two days of initiating VA-ECMO. Among the unweighted cohort, patients in the thrombolysis group were less likely to have poor consciousness at admission, out-of-hospital cardiac arrest, and left heart catheterization. After IPTW, the patient characteristics were well-balanced between the two groups The crude in-hospital mortality was 52% in the thrombolysis group and 61% in the control group. After IPTW, in-hospital mortality did not differ significantly between the two groups (risk difference: - 3.0%, 95% confidence interval: - 9.6% to 3.5%). There were also no significant differences in the secondary outcomes. Sensitivity analyses showed a significant difference in major bleeding between the monteplase and control groups (risk difference: 6.9%, 95% confidence interval: 1.7% to 12.1%), excluding patients who received urokinase. There were no significant differences in the other sensitivity and subgroup analyses except for the total hospitalization cost. CONCLUSIONS Systemic thrombolysis was not associated with reduced in-hospital mortality or increased major bleeding in the high-risk PE patients receiving VA-ECMO. However, systemic thrombolysis with monteplase was associated with increased major bleeding.
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Affiliation(s)
- Yuji Nishimoto
- grid.416985.70000 0004 0378 3952Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Hiroyuki Ohbe
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033 Japan
| | - Hiroki Matsui
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033 Japan
| | - Mikio Nakajima
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033 Japan ,Emergency Life-Saving Technique Academy of Tokyo, Foundation for Ambulance Service Development, Tokyo, Japan
| | - Yusuke Sasabuchi
- grid.410804.90000000123090000Data Science Center, Jichi Medical University, Tochigi, Japan
| | - Yukihito Sato
- grid.413697.e0000 0004 0378 7558Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Tetsuya Watanabe
- grid.416985.70000 0004 0378 3952Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takahisa Yamada
- grid.416985.70000 0004 0378 3952Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Masatake Fukunami
- grid.416985.70000 0004 0378 3952Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Hideo Yasunaga
- grid.26999.3d0000 0001 2151 536XDepartment of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 1130033 Japan
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Carroll BJ, Larnard EA, Pinto DS, Giri J, Secemsky EA. Percutaneous Management of High-Risk Pulmonary Embolism. Circ Cardiovasc Interv 2023; 16:e012166. [PMID: 36744463 DOI: 10.1161/circinterventions.122.012166] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.
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Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emily A Larnard
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Duane S Pinto
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jay Giri
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia (E.A.S.)
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Poor H, Serrao G, Grapsa J, Chandrashekhar YS, Bianco A, Lookstein RA, Fuster V. High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways. J Am Coll Cardiol 2023; 81:283-291. [PMID: 36265527 DOI: 10.1016/j.jacc.2022.10.004] [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] [Received: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
Abstract
While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.
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Affiliation(s)
- Hooman Poor
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Gregory Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julia Grapsa
- Department of Cardiovascular Sciences, Guys and St Thomas NHS Trust, Long, United Kingdom
| | | | - Angela Bianco
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert A Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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36
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Nasser MF, Jabri A, Sharma S, Alhuneafat L, Omar YA, Krishnan V, Cameron SJ. Outcomes with use of extra-corporeal membrane oxygenation in high-risk pulmonary embolism: a national database perspective. J Thromb Thrombolysis 2023; 55:499-505. [PMID: 36662443 DOI: 10.1007/s11239-023-02773-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/07/2023] [Indexed: 01/21/2023]
Abstract
High-risk pulmonary embolism (PE) patients can be managed with systemic lysis, catheter-based therapies, or surgical embolectomy. Despite the advent of newer therapies, patients with high-risk PE remain with a 50-60% short-term mortality risk. In such patients, extracorporeal membrane oxygenation (ECMO) is increasingly utilized for hemodynamic support. To evaluate the outcomes of the use of ECMO in patients with high-risk PE. Using the National Inpatient Sample (NIS) database, we identified patients with high-risk PE using ICD 10 codes and compared in-hospital outcomes of patients with and without ECMO support. We identified 38,035 patients with high-risk PE, of whom 820 had undergone ECMO placement. Most patients who underwent ECMO were male (54%), white (65%), and with a mean age of 53.7 years. ECMO use was not associated with a meaningful difference in patient mortality when comparing treatment groups (OR, 1.32 ± 0.39; 0.74-2.35; p = 0.35). Rather, ECMO use was associated with a higher frequency of inpatient complications. ECMO use was not associated with a significant difference in patient mortality in patients with high-risk PE.
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Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Center, Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Ahmad Jabri
- Heart and Vascular Center, Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Shorabh Sharma
- Department of Internal Medicine, St. Barnabas Hospital Health System, New York, NY, USA
| | - Laith Alhuneafat
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, USA
| | - Yazan Abu Omar
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Vidya Krishnan
- Division of Pulmonary, Critical Care and Sleep Medicine, Case Western Reserve University, MetroHealth Campus, Cleveland, OH, USA
| | - Scott J Cameron
- Section of Vascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Desk J-35, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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Yu G, Wei DP, Xie H, Lu J, Zhao JL, Li S, Chen W, Wang RL. Salvage of venoarterial extracorporeal membrane oxygenation following prolonged cardiopulmonary resuscitation and failure of catheter-directed thrombectomy for massive pulmonary embolism in a young patient. World J Emerg Med 2023; 14:161-164. [PMID: 36911057 PMCID: PMC9999134 DOI: 10.5847/wjem.j.1920-8642.2023.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 10/02/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Ge Yu
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Dong-Po Wei
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Hui Xie
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Jian Lu
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
| | - Jun-Li Zhao
- Department of Cardiology, Shanghai Municipal Hospital of Traditional Chinese Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai 200071, China
| | - Shuang Li
- Department of Cardiology, Shanghai Fourth People's Hospital Affiliated to Tongji University, Shanghai 200434, China
| | - Wei Chen
- Department of Cardiology, Shanghai Fourth People's Hospital Affiliated to Tongji University, Shanghai 200434, China
| | - Rui-Lan Wang
- Department of Emergency and Critical Care Medicine, Shanghai General Hospital (Shanghai First People's Hospital), Shanghai Jiao Tong University School of Medicine, Shanghai 200080, China
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38
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Hockstein MA, Singam NS, Papolos AI, Kenigsberg BB. The Role of Echocardiography in Extracorporeal Membrane Oxygenation. Curr Cardiol Rep 2023; 25:9-16. [PMID: 36571660 DOI: 10.1007/s11886-022-01827-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation. RECENT FINDINGS During cannulation, ultrasound is used to confirm intended vascular access and appropriate inflow cannula positioning. While on ECMO, echocardiographic evaluation of ventricular loading conditions and hemodynamics, cannula positioning, and surveillance for intracardiac or aortic thrombi is needed for complication mitigation. Echocardiography is crucial during all phases of ECMO use. Specific echocardiographic queries depend on the ECMO type, V-V, or V-A, and the specific cannula configuration strategy employed.
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Affiliation(s)
- Maxwell A Hockstein
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma Singam
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA. .,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA.
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39
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Risk stratification and risk-adapted management of acute pulmonary embolism. Wien Klin Wochenschr 2023; 135:22-27. [PMID: 36344825 DOI: 10.1007/s00508-022-02104-0] [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: 08/11/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022]
Abstract
Pulmonary embolism is one of the leading causes of cardiovascular death in Europe. Rapid diagnosis and treatment initiation are essential, especially in hemodynamically unstable patients. For normotensive patients, the diagnostic workflow is based on the clinical probability of pulmonary embolism. Due to numerous differential diagnoses and a highly variable clinical presentation, diagnosis of acute pulmonary embolism still remains a clinical challenge. Computed tomography angiography is the common gold standard to confirm pulmonary embolism and bedside echocardiography adds a major impact in clinical decision making. The European Society of Cardiology guidelines serve as a framework for a standardized diagnostic approach and risk prediction. Based on vital signs, clinical scores, biomarkers and imaging results, four risk categories can be defined and treatment is accordingly. To optimize the individual management of critical patients, multidisciplinary pulmonary embolism response teams are increasingly designated in specialized centers. This article provides an overview of the current risk-adapted management of patients with acute pulmonary embolism.
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40
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[Pulmonary embolism]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:40-49. [PMID: 36625924 PMCID: PMC9838347 DOI: 10.1007/s00108-022-01460-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/11/2023]
Abstract
Pulmonary embolism is a frequent cardiovascular disease which in recent years has shown a reduction in the mortality but an increase in the incidence. Due to the optimization of clinical probability scores and the interpretation of the D‑dimer test, unnecessary examinations using computed tomography with respect to the exclusion of an acute pulmonary embolism can be avoided, also in pregnant women. The evaluation of the right ventricle contributes to a risk-adapted treatment. Treatment consists of anticoagulation, alone or in combination with reperfusion treatment, such as systemic thrombolysis and also catheter-assisted or surgical treatment. In addition to acute treatment of pulmonary embolisms, an adequate aftercare is important, particularly for the early detection of long-term sequelae. This review article summarizes the current recommendations of international guidelines for patients with pulmonary embolism, accompanied by clinical case examples and a critical discussion.
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41
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Vandenbriele C, Van Edom C, Tavazzi G. Anticoagulant management for transition from failed thrombolysis to extra-corporeal membrane oxygenation in patients with high-risk pulmonary embolism: A thoughtful approach. Int J Cardiol 2023; 370:378-380. [PMID: 36283541 DOI: 10.1016/j.ijcard.2022.10.138] [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] [Received: 09/13/2022] [Revised: 10/12/2022] [Accepted: 10/19/2022] [Indexed: 11/05/2022]
Abstract
Acute venous thromboembolism represents a spectrum of clinical syndromes of which high-risk pulmonary embolism (PE) with consecutive right ventricular failure and cardiogenic shock (CS) is the most severe presentation. First-line treatment options are surgical pulmonary embolectomy, systemic thrombolysis or catheter-based therapies. The role of mechanical circulatory support with veno-arterial extracorporeal membrane oxygenation (V-A-ECMO) is multifarious in this setting and can be considered as either a bridge to pulmonary artery reperfusion by any of the aforementioned options or as salvage bridge intervention for patients in refractory CS after failure of another treatment. In the subpopulation of patients that are placed on V-A-ECMO after failed thrombolysis, the mortality rates are among the highest, partially due to the high rates of bleeding events. The challenges in the interpretation of anticoagulant monitoring and, consequently, the titration of anticoagulation at least contribute to this high mortality. Here, we discuss the strengths and limitations of different anticoagulant parameters in this setting and propose an approach based on monitoring of Heparin anti-factor Xa (anti-Xa) assay and activated partial thromboplastin time (APTT) in parallel to drive unfractionated heparin (UFH) titration in patients with high-risk PE after fibrinolysis during the first 24 h on V-A-ECMO.
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Affiliation(s)
- Christophe Vandenbriele
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium; Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium; Department of Adult Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, UK.
| | - Charlotte Van Edom
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Guido Tavazzi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, University of Pavia, Pavia, Italy; Intensive Care Unit, Fondazione Policlinico San Matteo IRCCS, Pavia, Italy
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42
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Poor H, Serrao G, Grapsa J, Chandrashekhar Y, Bianco A, Lookstein RA, Fuster V. High-Risk Pulmonary Embolism During Labor: JACC Patient Care Pathways. JACC Case Rep 2022; 6:101650. [PMID: 36704055 PMCID: PMC9871077 DOI: 10.1016/j.jaccas.2022.10.001] [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: 09/07/2022] [Revised: 10/04/2022] [Accepted: 10/06/2022] [Indexed: 11/08/2022]
Abstract
While in labor, a 37-year-old woman developed acute dyspnea, hypoxemia, and tachycardia. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction, raising the suspicion of acute pulmonary embolism. The patient indeed had bilateral pulmonary embolism, necessitating percutaneous thrombectomy. Her course was complicated by another saddle pulmonary embolus, heparin-induced thrombocytopenia, and COVID-19 infection. This clinical case illustrates the importance of prompt diagnosis of acute pulmonary embolism in a peripartum female patient, the multidisciplinary approach of management, and how to approach clinical complications such as heparin-induced thrombocytopenia. Furthermore, long-term management in acute pulmonary embolism is presented.
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Key Words
- CT, computed tomography
- CTA, computed tomography angiogram
- CTPA, computed tomography pulmonary angiography
- ECMO, extracorporeal membrane oxygenation
- HIT, heparin-induced thrombocytopenia
- LV, left ventricle
- PE, pulmonary embolism
- PVR, pulmonary vascular resistance
- RV, right ventricle
- SBP, systolic blood pressure
- TTE, transthoracic echocardiogram
- multimodality imaging
- pregnancy
- pulmonary embolism
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Affiliation(s)
- Hooman Poor
- Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA,Address for correspondence: Dr Hooman Poor, Division of Pulmonary, Critical Care, and Sleep Medicine, Icahn School of Medicine at Mount Sinai, 10 East 102nd Street, New York, New York 10029, USA. @jgrapsa
| | - Gregory Serrao
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Julia Grapsa
- Department of Cardiovascular Sciences, Guys and St Thomas NHS Trust, Long, United Kingdom
| | | | - Angela Bianco
- Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Robert A. Lookstein
- Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Valentin Fuster
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Pruszczyk P, Klok FA, Kucher N, Roik M, Meneveau N, Sharp ASP, Nielsen-Kudsk JE, Obradović S, Barco S, Giannini F, Stefanini G, Tarantini G, Konstantinides S, Dudek D. Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary Circulation and Right Ventricular Function and the European Association of Percutaneous Cardiovascular Interventions. EUROINTERVENTION 2022; 18:e623-e638. [PMID: 36112184 PMCID: PMC10241264 DOI: 10.4244/eij-d-22-00246] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/25/2022] [Indexed: 07/25/2023]
Abstract
There is a growing clinical and scientific interest in catheter-directed therapy (CDT) of acute pulmonary embolism (PE). Currently, CDT should be considered for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed. Also, CDT is a treatment option for initially stable patients in whom anticoagulant treatment fails, i.e., those who experience haemodynamic deterioration despite adequately dosed anticoagulation. However, the definition of treatment failure (primary reperfusion therapy or anticoagulation alone) remains an important area of uncertainty. Moreover, several techniques for CDT are available without evidence supporting one over the other, and variation in practice with regard to periprocedural anticoagulation is considerable. The aim of this position paper is to describe the currently available CDT approaches in PE patients and to standardise patient selection, the timing and technique of the procedure itself as well as anticoagulation regimens during CDT. We discuss several clinical scenarios of the clinical evaluation of the "efficacy" of thrombolysis and anticoagulation, including treatment failure with haemodynamic deterioration and treatment failure based on a lack of improvement. This clinical consensus statement serves as a practical guide for CDT, complementary to the formal guidelines.
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Affiliation(s)
- Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Frederikus A Klok
- Department of Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Nicolas Meneveau
- Hôpital Jean Minjoz, Besançon, France and University of Burgundy Franche-Comté, Besançon, France
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, UK and University of Exeter, Exeter, UK
| | | | - Slobodan Obradović
- Clinic of Cardiology, Military Medical Academy, School of Medicine, University of Defence, Belgrade, Serbia
| | - Stefano Barco
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Francesco Giannini
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
| | - Giulio Stefanini
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Giuseppe Tarantini
- Department of Cardiac, Thoracic, and Vascular Sciences and Public Health, University of Padova, Policlinico Universitario, Padova, Italy
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Komotini, Greece
| | - Dariusz Dudek
- Interventional Cardiology Unit, GVM Care and Research, Maria Cecilia Hospital, Cotignola, Italy
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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44
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Kochar A, Bergmark BA. Catheter-directed interventions for pulmonary embolism. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:721-727. [PMID: 35905304 DOI: 10.1093/ehjacc/zuac089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 07/12/2022] [Indexed: 06/15/2023]
Abstract
Pulmonary embolism (PE) is common, life-threatening, and often recurrent among survivors. The clinical manifestations of PE range from incidental detection to sudden death, with approximately one-third of PE deaths occurring suddenly. State-of-the-art management of acute PE relies on early detection, risk stratification based on clinical, imaging, and biomarker criteria, and multidisciplinary decision-making. The primary goal of catheter-directed interventions for acute PE is to interrupt the cycle of right ventricular failure, hypoperfusion, and oxygen supply/demand imbalance by increasing the cross-sectional area of the patent pulmonary vasculature, thereby lowering resistance and alleviating V/Q mismatch. Innovations in percutaneous interventions have led to several approaches described in this review: rheolytic thrombectomy, catheter-directed thrombolysis, and aspiration or mechanical thrombectomy. The central challenge moving forward will be integrating growing clinical trial evidence into multidisciplinary, individualized care pathways meeting the diverse clinical needs of patients presenting with acute PE.
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Affiliation(s)
- Ajar Kochar
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Brian A Bergmark
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
- Thrombolysis in Myocardial Infarction (TIMI) Study Group, Hale Building for Transformative Medicine, 60 Fenwood Road, Suite 7022, Boston, MA 02115, USA
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45
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Kuroda T, Miyagi C, Fukamachi K, Karimov JH. Mechanical circulatory support devices and treatment strategies for right heart failure. Front Cardiovasc Med 2022; 9:951234. [PMID: 36211548 PMCID: PMC9538150 DOI: 10.3389/fcvm.2022.951234] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
The importance of right heart failure (RHF) treatment is magnified over the years due to the increased risk of mortality. Additionally, the multifactorial origin and pathophysiological mechanisms of RHF render this clinical condition and the choices for appropriate therapeutic target strategies remain to be complex. The recent change in the United Network for Organ Sharing (UNOS) allocation criteria of heart transplant may have impacted for the number of left ventricular assist devices (LVADs), but LVADs still have been widely used to treat advanced heart failure, and 4.1 to 7.4% of LVAD patients require a right ventricular assist device (RVAD). In addition, patients admitted with primary left ventricular failure often need right ventricular support. Thus, there is unmet need for temporary or long-term support RVAD implantation exists. In RHF treatment with mechanical circulatory support (MCS) devices, the timing of the intervention and prediction of duration of the support play a major role in successful treatment and outcomes. In this review, we attempt to describe the prevalence and pathophysiological mechanisms of RHF origin, and provide an overview of existing treatment options, strategy and device choices for MCS treatment for RHF.
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Affiliation(s)
- Taiyo Kuroda
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Chihiro Miyagi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Kiyotaka Fukamachi
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
| | - Jamshid H. Karimov
- Department of Biomedical Engineering, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Biomedical Engineering, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, United States
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46
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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: 6] [Impact Index Per Article: 3.0] [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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47
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48
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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: 3] [Impact Index Per Article: 1.5] [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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49
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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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50
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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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