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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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Thakkar D, Shinde V. Caught in the Clot: A Case Report of Arrested Pulmonary Embolism. Cureus 2024; 16:e61213. [PMID: 38939235 PMCID: PMC11210831 DOI: 10.7759/cureus.61213] [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: 05/08/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition resulting from the obstruction of pulmonary arteries by blood clots, usually originating from deep veins. Symptoms of PE might vary from nothing to sudden death. Clinically, individuals may present very differently. When a diagnosis of PE is suspected, any possible life-saving intervention must be implemented because survival from cardiac arrest following PE is often quite low. Although there are not many randomized controlled trials that provide guidelines for treating suspected PE in cardiac arrest victims, the few published case reports and other minor studies suggest that thrombolysis and other therapies are associated with good outcomes. We report a patient with PE who presented in cardiac arrest with its clinical, electrographic, and radiologic findings, along with the appropriate therapy chosen based on hemodynamic stability. It is important to intervene early to prevent severe complications and improve the patient's outcomes.
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Affiliation(s)
- Dhruvkumar Thakkar
- Emergency Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
| | - Varsha Shinde
- Emergency Medicine, Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth (Deemed to be University), Pune, IND
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Thevathasan T, Füreder L, Fechtner M, Mørk SR, Schrage B, Westermann D, Linde L, Gregers E, Andreasen JB, Gaisendrees C, Unoki T, Axtell AL, Takeda K, Vinogradsky AV, Gonçalves-Teixeira P, Lemaire A, Alonso-Fernandez-Gatta M, Sern Lim H, Garan AR, Bindra A, Schwartz G, Landmesser U, Skurk C. Left-Ventricular Unloading With Impella During Refractory Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis. Crit Care Med 2024; 52:464-474. [PMID: 38180032 PMCID: PMC10876179 DOI: 10.1097/ccm.0000000000006157] [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: 01/06/2024]
Abstract
OBJECTIVES Extracorporeal cardiopulmonary resuscitation (ECPR) is the implementation of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during refractory cardiac arrest. The role of left-ventricular (LV) unloading with Impella in addition to VA-ECMO ("ECMELLA") remains unclear during ECPR. This is the first systematic review and meta-analysis to characterize patients with ECPR receiving LV unloading and to compare in-hospital mortality between ECMELLA and VA-ECMO during ECPR. DATA SOURCES Medline, Cochrane Central Register of Controlled Trials, Embase, and abstract websites of the three largest cardiology societies (American Heart Association, American College of Cardiology, and European Society of Cardiology). STUDY SELECTION Observational studies with adult patients with refractory cardiac arrest receiving ECPR with ECMELLA or VA-ECMO until July 2023 according to the Preferred Reported Items for Systematic Reviews and Meta-Analysis checklist. DATA EXTRACTION Patient and treatment characteristics and in-hospital mortality from 13 study records at 32 hospitals with a total of 1014 ECPR patients. Odds ratios (ORs) and 95% CI were computed with the Mantel-Haenszel test using a random-effects model. DATA SYNTHESIS Seven hundred sixty-two patients (75.1%) received VA-ECMO and 252 (24.9%) ECMELLA. Compared with VA-ECMO, the ECMELLA group was comprised of more patients with initial shockable electrocardiogram rhythms (58.6% vs. 49.3%), acute myocardial infarctions (79.7% vs. 51.5%), and percutaneous coronary interventions (79.0% vs. 47.5%). VA-ECMO alone was more frequently used in pulmonary embolism (9.5% vs. 0.7%). Age, rate of out-of-hospital cardiac arrest, and low-flow times were similar between both groups. ECMELLA support was associated with reduced odds of mortality (OR, 0.53 [95% CI, 0.30-0.91]) and higher odds of good neurologic outcome (OR, 2.22 [95% CI, 1.17-4.22]) compared with VA-ECMO support alone. ECMELLA therapy was associated with numerically increased but not significantly higher complication rates. Primary results remained robust in multiple sensitivity analyses. CONCLUSIONS ECMELLA support was predominantly used in patients with acute myocardial infarction and VA-ECMO for pulmonary embolism. ECMELLA support during ECPR might be associated with improved survival and neurologic outcome despite higher complication rates. However, indications and frequency of ECMELLA support varied strongly between institutions. Further scientific evidence is urgently required to elaborate standardized guidelines for the use of LV unloading during ECPR.
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Affiliation(s)
- Tharusan Thevathasan
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Lisa Füreder
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | - Marie Fechtner
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
| | | | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jo Bønding Andreasen
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | | | - Takashi Unoki
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Koji Takeda
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | - Alice V Vinogradsky
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
| | | | - Anthony Lemaire
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Marta Alonso-Fernandez-Gatta
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
| | - Hoong Sern Lim
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Arthur Reshad Garan
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
| | - Amarinder Bindra
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Gary Schwartz
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
- Department of Cardiology and Angiology, Medical Faculty, University Heart Center Freiburg, Bad Krozingen, University of Freiburg, Freiburg, Germany
- Department of Cardiology, Odense University Hospital, Odense, Denmark
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Aneastesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
- Department of Cardiology and Intensive Care Unit, Saiseikai Kumamoto Hospital, Kumamoto, Japan
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Surgery, Columbia University Medical Center/New York-Presbyterian Hospital, New York, NY
- Department of Cardiology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Oporto, Portugal
- Division of Cardiothoracic Surgery, Department of Surgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Cardiology Department, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
- Centro de Investigación biomédica en Red de Enfermadades Cardiovasculares (CIBER-CV), Madrid, Spain
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
- Division of Cardiology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
- Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, TX
| | - Carsten Skurk
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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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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5
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Esmaeeli S, Kashani S, Nozari A. Thrombolysis for pulmonary embolism cardiac arrest after large hemispheric stroke: The lesser of two evils? Resusc Plus 2022; 10:100249. [PMID: 35607397 PMCID: PMC9123260 DOI: 10.1016/j.resplu.2022.100249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 10/27/2022] Open
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Gaughran J, Lyne T, Kopeika J, Hamilton J. Ovarian hyperstimulation syndrome: cardiac arrest with an unexpected outcome. BMJ Case Rep 2021; 14:e246780. [PMID: 34799395 PMCID: PMC8606776 DOI: 10.1136/bcr-2021-246780] [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] [Accepted: 10/23/2021] [Indexed: 11/03/2022] Open
Abstract
We describe the acute deterioration of a 29-year-old undergoing in vitro fertilisation. Late-onset critical ovarian hyperstimulation syndrome triggered a massive pulmonary embolism and subsequent cardiac arrest. While the prognosis was deemed to be poor, the patient made a full recovery. The potential reasons for this are explored.
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Affiliation(s)
- Jonathan Gaughran
- Departement of Gynaecology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Tom Lyne
- School of Medical Education, King's College London, London, UK
| | - Julia Kopeika
- Assisted Conception Unit, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Judith Hamilton
- Departement of Gynaecology, Guy's and St Thomas' Hospitals NHS Trust, London, UK
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7
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Pyo SY, Park GJ, Kim SC, Kim H, Lee SW, Lee JH. Return of spontaneous circulation in patients with out-of-hospital cardiac arrest caused by pulmonary embolism using early point-of-care ultrasound and timely thrombolytic agent application: Two case reports. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920964136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Acute pulmonary embolism is a confirmed cause of up to 5% of out-of-hospital cardiac arrest and 5%–13% of unexplained cardiac arrest in patients. However, the true incidence may be much higher, as pulmonary embolism is often clinically underdiagnosed. Thrombolytic therapy is a recognized therapy for pulmonary embolism–associated cardiac arrest but is not routinely recommended during cardiopulmonary resuscitation. Therefore, clinicians should attempt to identify patients with suspected pulmonary embolism. Many point-of care ultrasound protocols suggest diagnosis of pulmonary embolism for cardiac arrest patients. Case presentation: We describe two male patients (60 years and 66 years, respectively) who presented to the emergency department with cardiac arrest within a period of 1 week. With administration of point-of care ultrasound during the ongoing cardiopulmonary resuscitation in both patients, fibrinolytic therapy was initiated under suspicion of cardiac arrest caused by pulmonary embolism. Both patients had return of spontaneous circulation; however, only the second patient, who received fibrinolytic therapy relatively early, was discharged with a good outcome. In this report, we discussed how to diagnose and manage patients with cardiac arrest–associated pulmonary embolism with the help of point-of care ultrasound. We also discuss the different clinical outcomes of the two patients based on the experience of the clinicians and the timing of thrombolytic agent application. Conclusions: If acute pulmonary embolism is suspected in patients with out-of-hospital cardiac arrest, we recommend prompt point-of care ultrasound examination. Point-of care ultrasound may help identify patients with pulmonary embolism during cardiopulmonary resuscitation, leading to immediate treatment, although the clinical outcomes may vary.
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Affiliation(s)
- Su Yeong Pyo
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Gwan Jin Park
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Sang Chul Kim
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Hoon Kim
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Suk Woo Lee
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
- Department of Emergency Medicine, College of Medicine, Chungbuk National University, Cheongju, Republic of Korea
| | - Ji Han Lee
- Department of Emergency Medicine, Chungbuk National University Hospital, Cheongju, Republic of Korea
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Mata R, McDermott G, Diaz L. Massive Pulmonary Embolism as a Cause of Cardiac Arrest: Navigating Unknowns in Life After Death. Cureus 2020; 12:e8361. [PMID: 32617232 PMCID: PMC7325409 DOI: 10.7759/cureus.8361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Pulmonary embolism (PE) is a common diagnosis with a low associated mortality rate. More critical variants, such as massive PE, also known as fulminant PE, are characterized by severe hemodynamic instability and have a markedly higher mortality rate. These variants can later develop in previously low to intermediate-risk patients and precipitate cardiac arrest within hours of symptom onset. The high mortality rate associated with massive PE is confounded by the difficulty in identifying patients most at risk of decompensating and a lack of clear treatment guidelines. We present the case of a patient at low to intermediate-high risk upon admission, and after failing systemic thrombolysis, decompensated, and went into cardiac arrest. This article serves to reinforce the need to closely monitor these patients due to the insufficiency of prognostic scores to predict decompensation and highlights the need for further research. We advocate the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as means of stabilization and will discuss various therapeutic alternatives.
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Affiliation(s)
- Robin Mata
- Internal Medicine, Nova Southeastern University School of Osteopathic Medicine, Fort Lauderdale, USA
| | - Gabrielle McDermott
- Physical Medicine and Rehabilitation, Memorial Regional Hospital / Nova Southeastern University-Dr. Kiran C. Patel College of Osteopathic Medicine (KPCOM), Hollywood, USA
| | - Lorenzo Diaz
- Physical Medicine and Rehabilitation, Memorial Regional Hospital / Nova Southeastern University-Dr. Kiran C. Patel College of Osteopathic Medicine (KPCOM), Hollywood, USA
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Thind GS, Hanane T, Bribriesco A, Yun J, Anandamurthy B, Latifi M, Unai S, Krishnan S. Extracorporeal cardiopulmonary resuscitation in a patient with fulminant pulmonary embolism refractory to intraarrest thrombolysis. Perfusion 2019; 35:163-165. [PMID: 31328640 DOI: 10.1177/0267659119862932] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION A fulminant pulmonary embolism is a potentially reversible cause of cardiac arrest with a reported mortality rate of up to 95%. Therapeutic strategies for fulminant pulmonary embolism continue to evolve. CASE REPORT We present a case of a 38-year-old female who suffered an in-hospital cardiac arrest due to fulminant pulmonary embolism. Extracorporeal cardiopulmonary resuscitation (facilitated by the LUCAS™ mechanical chest compression device) was successfully performed in this patient following failure of intraarrest thrombolysis. DISCUSSION For the management of fulminant pulmonary embolism, utilization of clot-directed therapies, especially intraarrest thrombolysis, has garnered increasing traction and interest. However, this therapeutic approach has its limitations. Fortuitously, the emergence of extracorporeal cardiopulmonary resuscitation has added a new dimension to the treatment of fulminant pulmonary embolism. A protocolized approach to treatment can improve outcomes in these patients. CONCLUSION Extracorporeal cardiopulmonary resuscitation can be used as a salvage therapy in patients with fulminant pulmonary embolism in whom intraarrest thrombolysis has failed.
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Affiliation(s)
- Guramrinder Singh Thind
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarik Hanane
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Alejandro Bribriesco
- Department of Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - James Yun
- Department of Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Balaram Anandamurthy
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Mani Latifi
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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Peppard SR, Parks AM, Zimmerman J. Characterization of alteplase therapy for presumed or confirmed pulmonary embolism during cardiac arrest. Am J Health Syst Pharm 2019; 75:870-875. [PMID: 29880524 DOI: 10.2146/ajhp170450] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The dosing and administration of alteplase in cardiac arrest due to suspected or confirmed pulmonary embolism (PE) are characterized. METHODS This multicenter, retrospective, cohort study evaluated adult patients who received alteplase during PE-induced cardiac arrest at 16 medical centers. Outcomes analyzed included alteplase dosing characteristics, cardiopulmonary resuscitation survival, time to return of spontaneous circulation (ROSC), documented occurrence of major or minor bleeding, intensive care unit and hospital length of stay, and survival to discharge. RESULTS A total of 35 patients were included in the analysis. Forty-six percent of patients received alteplase by a bolus-only dosing strategy. The most common bolus-only alteplase dose was 50 mg. Patients in the bolus-only group had a significantly shorter mean time from cardiac arrest onset to alteplase administration (15.1 minutes) compared with both the infusion-only group (46.4 minutes) and the bolus-with-infusion group (48.0 minutes) (p = 0.006). The mean cumulative alteplase dose was significantly higher in patients who had ROSC than those who did not (90.6 and 69.4 mg, respectively; p = 0.03). Although there was a significant difference in the cardiac arrest survival between groups, there was no difference between dosing strategies and the attainment of ROSC, and survival to hospital discharge. CONCLUSION Among patients receiving alteplase for presumed or confirmed PE during cardiac arrest, the most common treatment was administration of a single 50-mg bolus of the thrombolytic agent. This treatment was received by all survivors of cardiac arrest.
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Affiliation(s)
- Sarah R Peppard
- Department of Pharmacy, Froedtert and the Medical College of Wisconsin, Milwaukee, WI .,Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI.
| | - Ann M Parks
- Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI.,Department of Pharmacy, Aurora Health Care, Milwaukee, WI
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Karaman K, Celik C, Oskay A, Armağan HH, Tomruk O. SUCCESSFUL TREATMENT OF PULMONARY EMBOLISM AND ASSOCIATED UPPER EXTREMITY ARTERY THROMBOSIS USING INTRAVENOUS ALTEPLASE: A CASE REPORT. JOURNAL OF EMERGENCY MEDICINE CASE REPORTS 2019. [DOI: 10.33706/jemcr.551134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Survival and neurological outcome with extracorporeal cardiopulmonary resuscitation for refractory cardiac arrest caused by massive pulmonary embolism: A two center observational study. Resuscitation 2019; 136:8-13. [DOI: 10.1016/j.resuscitation.2018.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/28/2018] [Accepted: 12/10/2018] [Indexed: 11/22/2022]
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13
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Reardon PM, Yadav K, Hendin A, Karovitch A, Hickey M. Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens. J Intensive Care Med 2018; 34:603-608. [DOI: 10.1177/0885066618789879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.
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Affiliation(s)
- Peter M. Reardon
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Ariel Hendin
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Alan Karovitch
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Hickey
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
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14
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Laher AE, Richards G. Cardiac arrest due to pulmonary embolism. Indian Heart J 2018; 70:731-735. [PMID: 30392514 PMCID: PMC6204441 DOI: 10.1016/j.ihj.2018.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/18/2017] [Accepted: 01/08/2018] [Indexed: 01/21/2023] Open
Abstract
Pulmonary embolism (PE) is a potentially life threatening clinical condition that is fairly non-specific in presentation. Massive pulmonary embolism (PE) without cardiac arrest has been associated with a mortality rate of 30%. However, when cardiac arrest ensues, mortality may be as high as 95%. Since outcomes of cardiac arrest following PE are generally dismal, any available potentially life-saving measure must be instituted when the diagnosis of PE is suspected. Despite a lack of randomized controlled trials guiding the management of suspected PE in the cardiac arrest victim, thrombolysis and other therapies have been associated with good outcomes in the handful of published case reports and other small studies.
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Affiliation(s)
- Abdullah Ebrahim Laher
- Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa; Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa.
| | - Guy Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, 7 Jubilee Road, Parktown, Johannesburg, 2193, South Africa.
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15
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Gao JP, Ying KJ. Thrombolysis during Extended Cardiopulmonary Resuscitation for Autoimmune-Related Pulmonary Embolism. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791602300308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Massive pulmonary embolism (MPE) is one of the potentially reversible causes of cardiac arrest and pulseless electrical activity. At present, a fear of lethal haemorrhage makes thrombolytic therapy prohibitive during cardiopulmonary resuscitation. Blood hypercoagulability in autoimmune disorders (such as autoimmune haemolytic anaemia) carries a risk of MPE. Prompt diagnosis is critical for timely thrombolytic intervention. We reported a 23-year-old female with 10 years medical history of autoimmune haemolytic anaemia developed cardiac arrest in our emergency intensive care unit. Electrocardiogram and echocardiogram findings indicated the possibility of MPE, so fibrinolytic therapy with alteplase was administered along with prolonged cardiopulmonary resuscitation. Her neurological recovery was generally good, and no major bleeding occurred. MPE was confirmed by computed tomography pulmonary angiography afterwards. We regard that once there is presumptive diagnosis of MPE, initiating early thrombolysis during cardiopulmonary resuscitation may be considered. (Hong Kong j.emerg.med. 2016;23:180-185)
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Affiliation(s)
- JP Gao
- Sir Run Run Shaw Hospital, Critical Care Department, Zhejiang University School of Medicine, Hangzhou 310016, China
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16
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Abstract
Anticoagulation has been shown to improve mortality in acute pulmonary embolism (PE). Initiation of anticoagulation should be considered when PE is strongly suspected and the bleeding risk is perceived to be low, even if acute PE has not yet been proven. Low-risk patients with acute PE are simply continued on anticoagulation. Severely ill patients with high-risk (massive) PE require aggressive therapy, and if the bleeding risk is acceptable, systemic thrombolysis should be considered. However, despite clear evidence that parenteral thrombolytic therapy leads to more rapid clot resolution than anticoagulation alone, the risk of major bleeding including intracranial bleeding is significantly higher when systemic thrombolytic therapy is administered. It has been demonstrated that right ventricular dysfunction, as well as abnormal biomarkers (troponin and brain natriuretic peptide) are associated with increased mortality in acute PE. In spite of this, intermediate-risk (submassive) PE comprises a fairly broad clinical spectrum. For several decades, clinicians and clinical trialists have worked toward a more aggressive, yet safe solution for patients with intermediate-risk PE. Standard-dose thrombolysis, low-dose systemic thrombolysis, and catheter-based therapy which includes a number of devices and techniques, with or without low-dose thrombolytic therapy, have offered potential solutions and this area has continued to evolve. On the basis of heterogeneity within the category of intermediate-risk as well as within the high-risk group of patients, we will focus on the use of systemic thrombolysis in carefully selected high- and intermediate-risk patients. In certain circumstances when the need for aggressive therapy is urgent and the bleeding risk is acceptable, this is an appropriate approach, and often the best one.
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Affiliation(s)
- Victor F Tapson
- Division of Pulmonary and Critical Care, Venous Thromboembolism and Pulmonary Vascular Disease Research, Pulmonary and Critical Care Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
| | - Oren Friedman
- Division of Pulmonary and Critical Care, Pulmonary and Critical Care Medicine, Cardiac Surgery Intensive Care Unit, Cedars-Sinai Medical Center, Los Angeles, CA
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17
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Gazmuri RJ, Patel DJ, Stevens R, Smith S. Circulatory collapse, right ventricular dilatation, and alveolar dead space: A triad for the rapid diagnosis of massive pulmonary embolism. Am J Emerg Med 2016; 35:936.e1-936.e4. [PMID: 28040384 DOI: 10.1016/j.ajem.2016.12.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022] Open
Abstract
A triad of circulatory collapse, right ventricular dilatation, and large alveolar dead space is proposed for the rapid diagnosis and treatment of massive pulmonary embolism. A 17year-old female on oral contraceptives collapsed at home becoming incoherent with shallow breathing. Paramedics initiated mechanical chest compression and transported the patient to our emergency department, arriving minimally responsive with undetectable blood pressure but having positive corneal reflexes and bradycardia with wide QRS. The trachea was intubated and goal-directed echocardiography revealed marked right ventricular dilatation with septal flattening. The arterial PCO2 was 40mmHg with an end-tidal PCO2 of 8mmHg, revealing a large alveolar dead space. Persistent hypotension, bradycardia, and fading alertness despite epinephrine and norepinephrine infusions prompted resumption of chest compression. Intravenous alteplase (10mg bolus over 10min followed by 90mg over 110min) begun 125min after collapse improved hemodynamic function within 10min allowing discontinuation of chest compression. Five and a half hours after starting alteplase, the patient was hemodynamically stable and had normal end-tidal PCO2. A CT-angiogram showed the pulmonary arteries free of emboli but a thrombus in the right common iliac vein. The patient recovered fully and was discharged home on warfarin 8days later. Based on this and other reports, we propose a triad of circulatory collapse, right ventricular dilatation, and large alveolar dead space for the rapid diagnosis and treatment of massive pulmonary embolism, with systemic fibrinolysis as the first-line intervention.
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Affiliation(s)
- Raúl J Gazmuri
- Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States; Resuscitation Institute, Rosalind Franklin University of Medicine and Science, North Chicago, IL, United States.
| | - Dimple J Patel
- Pharmacy Service, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States
| | - Rom Stevens
- Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States
| | - Shani Smith
- Section of Critical Care Medicine, Captain James A. Lovell Federal Health Care Center, North Chicago, IL, United States
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18
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Thrombolytic therapy delay is independent predictor of mortality in acute pulmonary embolism at emergency service. Kaohsiung J Med Sci 2016; 32:572-578. [DOI: 10.1016/j.kjms.2016.09.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/13/2016] [Accepted: 09/20/2016] [Indexed: 11/18/2022] Open
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19
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Long B, Koyfman A. Current Controversies in Thrombolytic Use in Acute Pulmonary Embolism. J Emerg Med 2016; 51:37-44. [DOI: 10.1016/j.jemermed.2016.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 12/01/2022]
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20
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Han S, Chaya C, Hoo GWS. Thrombolytic Therapy for Massive Pulmonary Embolism in a Patient With a Known Intracranial Tumor. J Intensive Care Med 2016; 21:240-5. [PMID: 16855059 DOI: 10.1177/0885066606287047] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective was to describe and review the use of thrombolytic therapy in a patient with an intracranial tumor and massive pulmonary embolism. This is the first reported case of a patient with a known glioblastoma multiforme and massive pulmonary embolism who was successfully treated with alteplase. Pulmonary embolism was demonstrated by a ventilation-perfusion scan and transthoracic echocardiogram with repeat studies demonstrating resolution of the thromboembolism and reperfusion of pulmonary vasculature. A review of the literature revealed that the incidence of intracranial hemorrhage with thrombolysis is <3% and compares favorably with the much higher mortality rate of 25% to ≥50% in patients with hemodynamically unstable pulmonary emboli. The benefit of thrombolysis may outweigh the risks of intracranial hemorrhage in these patients, and careful consideration for its use in these patients is warranted.
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Affiliation(s)
- Steve Han
- VA Greater Los Angeles Healthcare System, West Los Angeles Healthcare Center, Geffen School of Medicine at UCLA, Los Angeles, California 90073, USA
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21
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Yousuf T, Brinton T, Ahmed K, Iskander J, Woznicka D, Kramer J, Kopiec A, Chadaga AR, Ortiz K. Tissue Plasminogen Activator Use in Cardiac Arrest Secondary to Fulminant Pulmonary Embolism. J Clin Med Res 2016; 8:190-5. [PMID: 26858790 PMCID: PMC4737028 DOI: 10.14740/jocmr2452w] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2016] [Indexed: 11/12/2022] Open
Abstract
Background Tissue plasminogen activator (tPA) is used emergently to dissolve thrombi in the treatment of fulminant pulmonary embolism. Currently, there is a relative contraindication to tPA in the setting of traumatic or prolonged cardiopulmonary resuscitation > 10 minutes because of the risk of massive hemorrhage. Methods Our single-center, retrospective study investigated patients experiencing cardiac arrest (CA) secondary to pulmonary embolus. We compared the effectiveness of advanced cardiac life support with the administration of tPA vs. the standard of care consisting of advanced cardiac life support without thrombolysis. The primary endpoint was survival to discharge. Secondary endpoints were return of spontaneous circulation (ROSC), major bleeding, and minor bleeding. Results We analyzed 42 patients, of whom 19 received tPA during CA. Patients who received tPA were not associated with a statistically significant increase in survival to discharge (10.5% vs. 8.7%, P = 1.00) or ROSC (47.4% vs. 47.8%, P = 0.98) compared to the control group. We observed no statistically significant difference between the groups in major bleeding events (5.3% in the tPA group vs. 4.3% in the control group, P = 1.00) and minor bleeding events (10.5% in the tPA group vs. 0.0% in the control group, P = 0.11). Conclusion This study did not find a statistically significant difference in survival to discharge or in ROSC in patients treated with tPA during CA compared to patients treated with standard therapy. However, because no significant difference was found in major or minor bleeding, we suggest that the potential therapeutic benefits of this medication should not be limited by the potential for massive hemorrhage. Larger prospective studies are warranted to define the efficacy and safety profile of thrombolytic use in this population.
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Affiliation(s)
- Tariq Yousuf
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Taylor Brinton
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Khansa Ahmed
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Joy Iskander
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Daniel Woznicka
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Jason Kramer
- Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Adam Kopiec
- Rosalind Franklin University of Medicine and Science, Chicago, IL, USA
| | - Amar R Chadaga
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
| | - Kathia Ortiz
- Department of Internal Medicine, Advocate Christ Medical Center, Oak Lawn, IL, USA
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22
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Lee H, Baek J, Park S, Jee D. Suspected Pulmonary Embolism during Hickman Catheterization in a Child: What Else Should Be Considered besides Pulmonary Embolism? Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.31.1.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Haemi Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Jonghyun Baek
- Department of Thoracic Surgery, College of Medicine, Yeungnam University, Daegu, Korea
| | - Sangyoung Park
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
| | - Daelim Jee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea
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23
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Double Bolus Thrombolysis for Suspected Massive Pulmonary Embolism during Cardiac Arrest. Case Rep Emerg Med 2015; 2015:367295. [PMID: 26664765 PMCID: PMC4664787 DOI: 10.1155/2015/367295] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/27/2015] [Accepted: 10/28/2015] [Indexed: 12/29/2022] Open
Abstract
More than 70% of cardiac arrest cases are caused by acute myocardial infarction (AMI) or pulmonary embolism (PE). Although thrombolytic therapy is a recognised therapy for both AMI and PE, its indiscriminate use is not routinely recommended during cardiopulmonary resuscitation (CPR). We present a case describing the successful use of double dose thrombolysis during cardiac arrest caused by pulmonary embolism. Notwithstanding the relative lack of high-level evidence, this case suggests a scenario in which recombinant tissue Plasminogen Activator (rtPA) may be beneficial in cardiac arrest. In addition to the strong clinical suspicion of pulmonary embolism as the causative agent of the patient's cardiac arrest, the extremely low end-tidal CO2 suggested a massive PE. The absence of dilatation of the right heart on subxiphoid ultrasound argued against the diagnosis of PE, but not conclusively so. In the context of the circulatory collapse induced by cardiac arrest, this aspect was relegated in terms of importance. The second dose of rtPA utilised in this case resulted in return of spontaneous circulation (ROSC) and did not result in haemorrhage or an adverse effect.
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24
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Abstract
Pulmonary embolism can present with a wide range of symptoms, from asymptomatic to cardiac arrest, making diagnosis challenging. Alteplase is a fibrinolytic that is indicated for the treatment of pulmonary embolism in intermediate- and high-risk patients. Controversy exists as to the patient population that will benefit most from fibrinolytic therapy, as well as the proper dose and administration technique. The patient's risk of bleeding should be weighed against the potential benefits of treatment in light of the clinical presentation because of the high mortality rate associated with pulmonary embolism. Nurses at the bedside must monitor for signs of bleeding when alteplase is administered. Fibrinolytic therapy will frequently be started in the emergency department, and the nurse must ensure that alteplase is administered in a safe and effective manner. This review discusses the clinical evidence for alteplase in pulmonary embolism and its specific role in treatment.
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25
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Yu Y, Zhai Z, Yang Y, Xie W, Wang C. Successful thrombolytic therapy of post-operative massive pulmonary embolism after ultralong cardiopulmonary resuscitation: a case report and review of literature. CLINICAL RESPIRATORY JOURNAL 2015; 11:383-390. [PMID: 26083151 DOI: 10.1111/crj.12332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 01/22/2015] [Accepted: 06/07/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIMS Cardiac arrest caused by massive pulmonary embolism (PE) is highly refractory to conventional resuscitation. Thrombolytic therapy has been considered to be an effective way to massive PE. METHODS We reported a case of successful thrombolytic therapy of post-operative massive PE after 90-min cardiopulmonary resuscitation (CPR) and reviewed the relevant literature. RESULTS We presented the case of a 48-year-old woman with surgery of varicosis of great saphenous vein who suffered from a massive PE with circulatory arrest refractory to 90 min of aggressive CPR. Thrombolysis was given only as a single dose of 50 mg of recombinant tissue plasminogen activator. Rapid haemodynamic and clinical improvement followed the bolus dose. The patient was discharged later without neurological or other sequelae. An extensive literature search of the PubMed database only identified 11 cases of massive PE with cardiac arrest during the perioperative period with a survival rate was 88.9%. The time period of CPR before thrombolysis or anti-coagulation was 15-90 min. CONCLUSIONS Thrombolytic therapy is useful to achieve the return of spontaneous circulation in the resuscitation of patients with cardiac arrest secondary to massive PE during the perioperative period, even in the prolong resuscitation.
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Affiliation(s)
- Yanxia Yu
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Zhenguo Zhai
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,National Clinical Research Center of Respiratory Disease; China-Japan Friendship Hospital. Yinghua Dongjie, Hepingli Beijing, China
| | - Yuanhua Yang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Wanmu Xie
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China
| | - Chen Wang
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Beijing Institute of Respiratory Medicine, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Respiratory and Pulmonary Circulation Disorders, Beijing, China.,National Clinical Research Center of Respiratory Disease; China-Japan Friendship Hospital. Yinghua Dongjie, Hepingli Beijing, China
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26
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Zhang ZP, Su X, Liu CW, Song D, Peng J, Wu MX, Yang YC, Liu B, Xu CY, Wang F. Thrombolysis during continuous chest compression in a patient with cardiac arrest due to pulmonary embolism: prolonged CPR-induced spinal cord injury. Am J Emerg Med 2015. [PMID: 26206242 DOI: 10.1016/j.ajem.2015.06.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Zhi-Ping Zhang
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Xi Su
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China.
| | - Cheng-Wei Liu
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Dan Song
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Jian Peng
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Ming-Xiang Wu
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Yu-Chun Yang
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Bo Liu
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Cheng-Yi Xu
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
| | - Fang Wang
- Cardiac Care Unit, Wuhan Asia Heart Hospital, Wuhan 430022, China
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27
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Gao JP, Ying KJ. Thrombolysis during extended cardiopulmonary resuscitation for autoimmune-related pulmonary embolism. World J Emerg Med 2015; 6:153-6. [PMID: 26056548 DOI: 10.5847/wjem.j.1920-8642.2015.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 01/29/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Massive pulmonary embolism (MPE) and acute myocardial infarction are the two most common causes of cardiac arrest (CA). At present, lethal hemorrhage makes thrombolytic therapy underused during cardiopulmonary resuscitation, despite the potential benefits for these underlying conditions. Hypercoagulability of the blood in autoimmune disorders (such as autoimmune hemolytic anemia) carries a risk of MPE. It is critical to find out the etiology of CA for timely thrombolytic intervention. METHODS A 23-year-old woman with a 10-year medical history of autoimmune hemolytic anemia suffered from CA in our emergency intensive care unit. ECG and echocardiogram indicated the possibility of MPE, so fibrinolytic therapy (alteplase) was successful during prolonged resuscitation. RESULTS Neurological recovery of the patient was generally good, and no fatal bleeding developed. MPE was documented by CT pulmonary angiography. CONCLUSIONS A medical history of autoimmune disease poses a risk of PE, and the causes of CA (such as this) should be investigated etiologically. A therapy with alteplase may be used early during cardiopulmonary resuscitation once there is presumptive evidence of PE. Clinical trials are needed in this setting to study patients with hypercoagulable states.
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Affiliation(s)
- Jian-Ping Gao
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ke-Jing Ying
- Department of Respiratory and Critical Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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28
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Wu JP, Gu DY, Wang S, Zhang ZJ, Zhou JC, Zhang RF. Good neurological recovery after rescue thrombolysis of presumed pulmonary embolism despite prior 100 minutes CPR. J Thorac Dis 2015; 6:E289-93. [PMID: 25590010 DOI: 10.3978/j.issn.2072-1439.2014.12.23] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/13/2014] [Indexed: 12/18/2022]
Abstract
We reported the case of a 70-year-old man who was admitted to neurologic wards for recurrent syncope for 3 years. Unfortunately, just 2 hours after his admission, he suddenly collapsed and failed to return of spontaneous circulation (ROSC) after a 100-minute standard cardiopulmonary resuscitation (CPR). Fortunately, he was timely suspected to have pulmonary embolism (PE) based on his sedentary lifestyle, elevated D-dimer and markedly enlarged right ventricle chamber on bedside echocardiography. After a rescue thrombolytic alteplase therapy, he was successfully resuscitated and good neurological recovery was achieved.
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Affiliation(s)
- Jiang-Ping Wu
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Dan-Yan Gu
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Sheng Wang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Zhen-Jun Zhang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jian-Cang Zhou
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Rui-Feng Zhang
- 1 Department of Emergency Medicine, The Second People's Hospital of Yiwu City, Yiwu 322002, China ; 2 Department of Critical Care Medicine, 3 Department of Respiratory Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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29
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PAVLOVIC G, BANFI C, TASSAUX D, PETER RE, LICKER MJ, BENDJELID K, GIRAUD R. Peri-operative massive pulmonary embolism management: is veno-arterial ECMO a therapeutic option? Acta Anaesthesiol Scand 2014; 58:1280-6. [PMID: 25251898 DOI: 10.1111/aas.12411] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 12/18/2022]
Abstract
Pulmonary embolism remains an important clinical problem with a high mortality rate. The potential for sudden and fatal hemodynamic deterioration highlights the need for a prompt diagnosis and appropriate intervention. The purpose of the present case report is to describe a successful peri-operative veno-arterial extra corporeal membrane oxygenation (VA-ECMO) implantation for assumed massive pulmonary embolism associated with high hemodynamic instability and severe hypoxemia. A 52-year-old female victim of a motorcycle accident had been operated on for unstable fractures that required optimal repair. Despite subcutaneous administration of 40 mg enoxaparin on day 0 and day 1, the patient developed a massive pulmonary embolism leading to peri-operative pulseless activity. As intravenous thrombolysis was strictly contraindicated, a VA-ECMO was successfully implanted and permitted to stabilize the patient's hemodynamics. The hemodynamic and respiratory status improved by day 3, and the ECMO was removed. A vena cava filter was implanted before successful and definitive stabilization of the femoral fracture and the L2 fracture on days 4 and 5. The patient was able to be mobilized 2 days after the surgery and was transferred to a rehabilitation ward on day 15. At that time, her cognitive functions had fully recovered. ECMO can provide lifesaving hemodynamic and respiratory support in patients with massive pulmonary embolism who are too unstable to tolerate other interventions, who have failed other therapies or for whom other therapies are contraindicated.
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Affiliation(s)
- G. PAVLOVIC
- Division of Anesthesiology; Geneva University Hospitals; Geneva Switzerland
| | - C. BANFI
- Division of Cardiovascular Surgery; Geneva University Hospitals; Geneva Switzerland
- Faculty of Medicine; University of Geneva; Geneva Switzerland
- Geneva Hemodynamic Research Group; Geneva Switzerland
| | - D. TASSAUX
- Intensive Care Service; Geneva University Hospitals; Geneva Switzerland
| | - R. E. PETER
- Division of Orthopedic Surgery; Geneva University Hospitals; Geneva Switzerland
- Faculty of Medicine; University of Geneva; Geneva Switzerland
| | - M. J. LICKER
- Division of Anesthesiology; Geneva University Hospitals; Geneva Switzerland
- Faculty of Medicine; University of Geneva; Geneva Switzerland
| | - K. BENDJELID
- Intensive Care Service; Geneva University Hospitals; Geneva Switzerland
- Faculty of Medicine; University of Geneva; Geneva Switzerland
- Geneva Hemodynamic Research Group; Geneva Switzerland
| | - R. GIRAUD
- Intensive Care Service; Geneva University Hospitals; Geneva Switzerland
- Faculty of Medicine; University of Geneva; Geneva Switzerland
- Geneva Hemodynamic Research Group; Geneva Switzerland
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30
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Yin Q, Li X, Li C. Thrombolysis after initially unsuccessful cardiopulmonary resuscitation in presumed pulmonary embolism. Am J Emerg Med 2014; 33:132.e1-2. [PMID: 25074694 DOI: 10.1016/j.ajem.2014.06.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 06/19/2014] [Indexed: 11/26/2022] Open
Abstract
The life-saving administration of thrombolytic therapy after initially unsuccessful cardiopulmonary resuscitation (CPR) in 7 patients with presumed pulmonary embolism (PE) was reported. Seven patients who had cardiac arrest were admitted to our emergency department. The clinical diagnosis of all these patients was highly suspected with PE; therefore, 50 mg recombinant tissue plasminogen activator with 50-mL dilution was administered in a 15-minute period after initially unsuccessful CPR. Of 7 patients, 5 (71.4%) achieved return of spontaneous circulation after CPR and thrombolytic therapy, and 3 (42.9%) of 7 patients were discharged alive through successive treatments. A 90-day follow-up showed that 2 patients were neurologically intact, and 1 patient was mildly disabled. These results demonstrate that thrombolysis after initially unsuccessful CPR in presumed PE may have beneficial effects.
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Affiliation(s)
- Qin Yin
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Xiao Li
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Chunsheng Li
- Emergency Department of Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.
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Trombectomia percutânea reolítica no tratamento de tromboembolismo pulmonar de alto risco: experiência inicial de um centro. Rev Port Cardiol 2014; 33:371-7. [DOI: 10.1016/j.repc.2014.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Revised: 01/28/2014] [Accepted: 02/01/2014] [Indexed: 11/22/2022] Open
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Faria R, Oliveira M, Ponte M, Pires-Morais G, Sousa M, Fernandes P, Rodrigues A, Braga P, Gonçalves M, Gama V. Percutaneous thrombectomy in the treatment of acute pulmonary embolism: Initial experience of a single center. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Prom R, Dull R, Delk B. Successful alteplase bolus administration for a presumed massive pulmonary embolism during cardiopulmonary resuscitation. Ann Pharmacother 2013; 47:1730-5. [PMID: 24259620 DOI: 10.1177/1060028013508644] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe the case of a patient successfully resuscitated with bolus alteplase for a presumed massive pulmonary embolism (PE) with associated cardiac arrest. CASE SUMMARY A 54-year-old man presented to the emergency department for evaluation of syncope following recent open reduction and internal fixation of his ankle. On arrival, his condition rapidly deteriorated and progressed to cardiopulmonary arrest. Because of noncompliance with postoperative thromboprophylaxis, there was high suspicion for PE. Following 40 minutes of advanced cardiac life support, empirical alteplase 50 mg was administered intravenously over 2 minutes with return of spontaneous circulation (ROSC) observed 6 minutes later. The diagnosis of PE using computed tomographic angiography was confirmed after fibrinolytic therapy. Although his hospital course was complicated by a gastrointestinal bleed requiring transfusion, he was discharged neurologically intact. DISCUSSION Clinical guidelines recommend fibrinolytic therapy for patients with PE and cardiac arrest. Data from retrospective analyses, case series, and case reports suggest that various fibrinolytic regimens may facilitate ROSC and improve neurologically intact survival without an increased risk of fatal hemorrhage. CONCLUSION The choice of fibrinolytic therapy should be based on hospital availability, with prompt initiation of treatment and incorporation of an intravenous bolus. A reasonable treatment regimen is alteplase 0.6 mg/kg (maximum of 50 mg) or fixed dose of alteplase 50 mg given over 2 to 15 minutes. Resuscitation should be continued for at least 30 minutes, or until ROSC, after fibrinolytic initiation to allow time for the medication to work.
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Acute Myocardial Infarction and Massive Pulmonary Embolus Presenting as Cardiac Arrest: Initial Rhythm as a Diagnostic Clue. Case Rep Emerg Med 2013; 2013:343918. [PMID: 23956886 PMCID: PMC3728547 DOI: 10.1155/2013/343918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Accepted: 06/26/2013] [Indexed: 11/21/2022] Open
Abstract
Myocardial infarction (MI) and massive pulmonary embolism (MPE) are common causes of cardiac arrest. We present two cases with similar clinical presentation and EKG findings but different initial rhythms. Case 1. A 55-year-old African American male (AAM) was brought to the emergency room (ER) with cardiac arrest and pulseless electrical activity (PEA). Twelve-lead electrocardiogram (EKG) was suggestive of ST segment elevations (STEs) in anterolateral leads. Coronary angiogram did not reveal any significant obstruction. An echocardiogram was suggestive of a pulmonary embolus (PE). Autopsy revealed a saddle PE. Case 2. A 45-year-old AAM with a history of coronary artery disease was brought to the ER after ventricular fibrillation (VF) arrest. Twelve-lead EKG was suggestive of STE in anterior leads. Coronary angiogram revealed in-stent thrombosis. In cardiac arrests, distinguishing the two major etiologies (MI and MPE) can be challenging. PEA is more commonly associated with MPE versus MI due to near complete obstruction of pulmonary blood flow with an intact electrical conduction system. MI is more commonly associated with VF as the electrical conduction system is affected more often by ischemia. In conclusion, the previous cases illustrate that initial rhythm may be a vital diagnostic clue.
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Successful resuscitation with thrombolysis of a presumed fulminant pulmonary embolism during cardiac arrest. Am J Emerg Med 2012; 31:453.e1-3. [PMID: 22980371 DOI: 10.1016/j.ajem.2012.06.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 06/29/2012] [Accepted: 06/30/2012] [Indexed: 11/22/2022] Open
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Gritti P, Fiocca L, Lanterna LA, Bowman J, Lunghi A. Direct intraclot thrombolysis for cardiac arrest following massive pulmonary embolism in a neurosurgical patient. Treating on the edge? Resuscitation 2011; 82:e15-7. [DOI: 10.1016/j.resuscitation.2011.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2011] [Accepted: 07/18/2011] [Indexed: 10/17/2022]
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37
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Fibrinolysis and thrombectomy for massive pulmonary embolus. Am J Ther 2011; 20:576-80. [PMID: 21317623 DOI: 10.1097/mjt.0b013e3182062e22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Treatment options for massive and submassive pulmonary embolus may include hemodynamic support, fibrinolysis, anticoagulation, and thrombectomy. Selection of the appropriate therapy requires scrutiny of the patient's hemodynamic status, preexisting conditions, risk of complications, and availability of services at the treatment center. This article illustrates a case of successful fibrinolysis and thrombectomy in a woman with massive pulmonary embolus. A discussion of the indications, benefits, and disadvantages of several pharmacologic, radiologic, and surgical interventions considered in pulmonary embolus will follow.
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Continuous mechanical chest compression during in-hospital cardiopulmonary resuscitation of patients with pulseless electrical activity. Resuscitation 2011; 82:155-9. [DOI: 10.1016/j.resuscitation.2010.10.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 08/30/2010] [Accepted: 10/29/2010] [Indexed: 11/23/2022]
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Perrott J, Henneberry RJ, Zed PJ. Thrombolytics for Cardiac Arrest: Case Report and Systematic Review of Controlled Trials. Ann Pharmacother 2010; 44:2007-13. [DOI: 10.1345/aph.1p364] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To describe a successful case involving the use of tenecteplase during cardiac arrest for presumed pulmonary embolism (PE) and to systematically review the evidence from controlled trials supporting the efficacy and safety of thrombolysis during cardiac arrest. Case Summary: A 48-year-old male presented to the emergency department with an acute onset of shortness of breath that began approximately 2 hours prior to presentation. Prior to undergoing a computed tomography (CT) scan to rule out PE, the patient went into cardiac arrest, with an initial rhythm of pulseless electrical activity at a rate of 140 beats/min. Cardiopulmonary resuscitation (CPR) was initiated and, due to suspected PE, a bolus dose of tenecteplase 50 mg was administered immediately following a single 1-mg dose of epinephrine. CPR was continued and 4 additional 1-mg doses of epinephrine and three 1-mg doses of atropine were given. After 13 minutes of CPR, return of spontaneous circulation (ROSC) was achieved, with a blood pressure of 144/50 mm Hg. After the patient was stabilized, a CT scan demonstrated extensive bilateral pulmonary emboli in most segmental arteries. He was admitted to the intensive care unit where he was sedated, paralyzed, and treated with induced hypothermia for 24 hours. He was discharged from the hospital 2 weeks later on warfarin, with no noted neurologic deficits. Discussion: A systematic search of MEDLINE (1950-August 2010), Embase (1980-August 2010), and Google Scholar (to August 2010) was conducted to identify prospective controlled trials that investigated the use of thrombolytic medications to treat cardiac arrest. Five trials involving 1544 undifferentiated cases of cardiac arrest were found. Overall, some trials reported an improved rate of ROSC following administration of thrombolytics, but there was no overall mortality reduction in any trial. There was, however, an increased risk of bleeding events following administration of a thrombolytic drug. Conclusions: Controlled trials demonstrate that there is a lack of benefit and potential harm in administering thrombolysis in an undifferentiated patient with cardiac arrest. However, the case we present provides evidence that fibrinolysis may benefit selected patients with cardiac arrest in whom PE is confirmed or in whom there is high index of suspicion of PE.
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Affiliation(s)
- Jerrold Perrott
- Critical Care, Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Ryan J Henneberry
- Department of Emergency Medicine, Capital Health, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Peter J Zed
- Department of Pharmacy and Pharmacotherapeutic Specialist—Emergency Medicine, Queen Elizabeth II Health Sciences Centre, Halifax, College of Pharmacy and Department of Emergency Medicine, Dalhousie University
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Er F, Nia AM, Gassanov N, Caglayan E, Erdmann E, Hoppe UC. Impact of rescue-thrombolysis during cardiopulmonary resuscitation in patients with pulmonary embolism. PLoS One 2009; 4:e8323. [PMID: 20016808 PMCID: PMC2788709 DOI: 10.1371/journal.pone.0008323] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 11/19/2009] [Indexed: 12/26/2022] Open
Abstract
Background Cardiac arrest in patients with pulmonary embolism (PE) is associated with high morbidity and mortality. Thrombolysis is expected to improve the outcome in these patients. However studies evaluating rescue-thrombolysis in patients with PE are missing, mainly due to the difficulties of clinical diagnosis of PE. We aimed to determine the success influencing factors of thrombolysis during resuscitation in patients with PE. Methodology/Principal Findings We analyzed retrospectively the outcome of 104 consecutive patients with confirmed (n = 63) or highly suspected (n = 41) PE and monitored cardiac arrest. In all patients rtPA was administrated for thrombolysis during cardiopulmonary resuscitation. In 40 of the 104 patients (38.5%) a return of spontaneous circulation (ROSC) could be achieved successfully. Patients with ROSC received thrombolysis significantly earlier after CPR onset compared to patients without ROSC (13.6±1.2 min versus 24.6±0.8 min; p<0.001). 19 patients (47.5%) out of the 40 patients with initially successful resuscitation survived to hospital discharge. In patients with hospital discharge thrombolysis therapy was begun with a significantly shorter delay after cardiac arrest compared to all other patients (11.0±1.3 vs. 22.5±0.9 min; p<0.001). Conclusion Rescue-thrombolysis should be considered and started in patients with PE and cardiac arrest, as soon as possible after cardiac arrest onset.
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Affiliation(s)
- Fikret Er
- Department of Internal Medicine III, University of Cologne, Cologne, Germany.
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41
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Cavallaro F, Sandroni C, Bocci MG, Marano C. Good neurological recovery after cardiopulmonary resuscitation and thrombolysis in two old patients with pulmonary embolism. Acta Anaesthesiol Scand 2009; 53:400-2. [PMID: 19243326 DOI: 10.1111/j.1399-6576.2008.01861.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The use of thrombolysis as an emergency treatment for cardiac arrest (CA) due to massive pulmonary embolism (MPE) has been described. However, there are no reports of successful treatment of MPE-associated CA in patients over 77 years of age. We report two cases of successful cardiopulmonary resuscitation for an MPE-associated CA in two very old women (87 and 86 years of age). In both cases, typical signs of MPE were documented using emergency echocardiography, which showed an acute right ventricle enlargement and a paradoxical movement of the interventricular septum. Emergency thrombolysis was administered during resuscitation, which lasted 45 and 21 min, respectively. Despite old age and prolonged resuscitation efforts, both patients had good neurological recovery and one of them was alive and neurologically intact 1 year later. Thrombolysis is a potentially useful therapy in MPE-associated CA. A good neurological outcome can be obtained even in very old patients and after prolonged resuscitation.
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Affiliation(s)
- F Cavallaro
- Department of Anaesthesiology and Intensive Care, Intensive Care Unit, Catholic University School of Medicine, Policlinico A. Gemelli, Rome, Italy.
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42
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Vanbrabant P, Sinnaeve PR. Thrombolysis in cardiac arrest: one size fits all or tailored to highly selected patients? Eur J Intern Med 2008; 19:473-5. [PMID: 19013372 DOI: 10.1016/j.ejim.2008.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Accepted: 03/11/2008] [Indexed: 10/22/2022]
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43
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Flores J, de Tena JG, de Pablo R, Daguerre M. Successful outcome of cardiopulmonary arrest with systemic thrombolysis. Eur J Intern Med 2008; 19:e38-9. [PMID: 18848167 DOI: 10.1016/j.ejim.2008.01.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2007] [Accepted: 01/21/2008] [Indexed: 11/28/2022]
Affiliation(s)
- Julio Flores
- Servicio de Neumología, Hospital Universitario Príncipe de Asturias, Crta Alcalá-Meco s/n 28805 Alcalá de Henares, Madrid, Spain
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45
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Ruiz-Bailén M, López-Caler C, Castillo-Rivera A, Rucabado-Aguilar L, Ramos Cuadra JA, Lara Toral J, Lozano Cabezas C, Fernández Guerrero JC. Giant right atrial thrombi treated with thrombolysis. Can J Cardiol 2008; 24:312-4. [PMID: 18401474 DOI: 10.1016/s0828-282x(08)70183-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
The present report describes giant atrial thrombi that were treated with thrombolysis in a community hospital. Two patients with giant atrial thrombi whose treatment involved complications are presented. Both patients developed cardiogenic shock and were treated unsuccessfully with thrombolysis. Because thrombolysis of giant thrombi may be ineffective, patients in this situation may require surgery.
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Affiliation(s)
- Manuel Ruiz-Bailén
- Critical Care and Emergencies Department, Hospital Universitario Médico-Quirúrgico, Jaén, Spain.
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46
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Hefer DVF, Munir A, Khouli H. Low-dose tenecteplase during cardiopulmonary resuscitation due to massive pulmonary embolism: a case report and review of previously reported cases. Blood Coagul Fibrinolysis 2007; 18:691-4. [PMID: 17890959 DOI: 10.1097/mbc.0b013e3282a167a7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The case of a 29 year-old man who suffered a cardiac arrest due to a massive pulmonary embolism while he was undergoing surgical repair of a complex tibial plateau fracture is presented. After 70 min of unsuccessful cardiopulmonary resuscitation a bolus of 20 mg tenecteplase was given, with a return of spontaneous circulation 2 min after administration of the drug. Pulmonary embolism was subsequently demonstrated on a pulmonary angiogram. To our knowledge this is the first report to show that the use of a low dose of tenecteplase might be useful to achieve the return of spontaneous circulation in the resuscitation of patients with cardiac arrest secondary to massive pulmonary embolism. Previously reported cases are reviewed.
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Affiliation(s)
- David Václav Fred Hefer
- Cardiovascular Research Center, University of Vermont, College of Medicine, Burlington, Vermont, USA.
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47
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Keuper W, Dieker HJ, Brouwer MA, Verheugt FW. Reperfusion therapy in out-of-hospital cardiac arrest: Current insights. Resuscitation 2007; 73:189-201. [DOI: 10.1016/j.resuscitation.2006.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 07/26/2006] [Accepted: 08/03/2006] [Indexed: 10/23/2022]
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48
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Ruiz-Bailén M, Narbona-Carvo B, Ramos-Cuadra JA, Rucabado-Aguilar L, López-Caler C, Gómez-Jiménez FJ. Systemic thrombolysis for prosthetic valve thrombosis in the immediate postoperative period of major abdominal surgery. J Thorac Cardiovasc Surg 2007; 133:801-3. [PMID: 17320589 DOI: 10.1016/j.jtcvs.2006.10.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2006] [Revised: 10/18/2006] [Accepted: 10/24/2006] [Indexed: 11/28/2022]
Affiliation(s)
- Manuel Ruiz-Bailén
- Intensive Care Unit, Critical Care and Emergencies Department, Medico-Surgical University Hospital, Jaén Hospital Complex, Jaén, Spain.
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49
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Dager WE, Sanoski CA, Wiggins BS, Tisdale JE. Pharmacotherapy considerations in advanced cardiac life support. Pharmacotherapy 2007; 26:1703-29. [PMID: 17125434 DOI: 10.1592/phco.26.12.1703] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Cardiac arrest and sudden cardiac death remain major causes of mortality. Early intervention has been facilitated by emergency medical response systems and the development of training programs in basic life support and advanced cardiac life support (ACLS). Despite the implementation of these programs, the likelihood of a meaningful outcome in many life-threatening situations remains poor. Pharmacotherapy plays a role in the management of patients with cardiac arrest, with new guidelines for ACLS available in 2005 providing recommendations for the role of specific drug therapies. Epinephrine continues as a recommended means to facilitate defibrillation in patients with pulseless ventricular tachycardia or ventricular fibrillation; vasopressin is an alternative. Amiodarone is the primary antiarrhythmic drug that has been shown to be effective for facilitation of defibrillation in patients with pulseless ventricular tachycardia or fibrillation and is also used for the management of atrial fibrillation and hemodynamically stable ventricular tachycardia. Epinephrine and atropine are the primary agents used for the management of asystole and pulseless electrical activity. Treatment of electrolyte abnormalities, severe hypotension, pulmonary embolism, acute ischemic stroke, and toxicologic emergencies are important components of ACLS management. Selection of the appropriate drug, dose, and timing and route of administration are among the many challenges faced in this setting. Pharmacists who are properly educated and trained regarding the use of pharmacotherapy for patients requiring ACLS can help maximize the likelihood of positive patient outcomes.
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Affiliation(s)
- William E Dager
- University of California-Davis Medical Center, and the School of Medicine, University of California-Davis, Sacramento, California 95817-2201, USA.
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Koroneos A, Koutsoukou A, Zervakis D, Politis P, Sourlas S, Pagoni E, Roussos C. Successful resuscitation with thrombolysis of a patient suffering fulminant pulmonary embolism after recent intracerebral haemorrhage. Resuscitation 2006; 72:154-7. [PMID: 17084012 DOI: 10.1016/j.resuscitation.2006.06.019] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2006] [Revised: 06/07/2006] [Accepted: 06/12/2006] [Indexed: 11/20/2022]
Abstract
We report the life-saving administration of thrombolysis during cardiopulmonary resuscitation in a patient with recent intracerebral haemorrhage. A 53-year-old male with intracerebral haemorrhage was admitted to the intensive care unit. On the 24th day of treatment he suffered cardiac arrest with pulseless electrical activity. Transoesophageal echocardiography was performed during ongoing cardiopulmonary resuscitation. Thrombi in the right heart cavities with excessive right ventricular dysfunction confirmed the diagnosis of fulminant pulmonary embolism. Permanent restoration of a spontaneous rhythm was feasible only after administration of systemic thrombolysis with recombinant tissue plasminogen activator. Neurological examination and a computed tomogram of the brain did not show rebleeding. We conclude that under extreme circumstances absolute contraindications to thrombolysis should be weighed against the potential benefit.
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Affiliation(s)
- Apostolos Koroneos
- Department of Pulmonary and Critical Care Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece.
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