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Carlon TA, Goldman DT, Marinelli BS, Korff RA, Watchmaker JM, Patel RS, Lipson SD, Bishay VL, Lookstein RA. Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy. Radiographics 2022; 42:1861-1880. [PMID: 36190861 DOI: 10.1148/rg.220026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ©RSNA, 2022.
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Affiliation(s)
- Timothy A Carlon
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Daryl T Goldman
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Brett S Marinelli
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Ricki A Korff
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Jennifer M Watchmaker
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Rahul S Patel
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Scott D Lipson
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Vivian L Bishay
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
| | - Robert A Lookstein
- From the Department of Diagnostic, Molecular, and Interventional Radiology (T.A.C., D.T.G., B.S.M., R.A.K., J.M.W., R.S.P., V.L.B., R.A.L.) and Department of Anesthesiology (S.D.L.), Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1234, New York, NY 10029
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Wang HC, Long X. Filler-induced non-thrombotic pulmonary embolism after genital aesthetic injection. J COSMET LASER THER 2022; 24:66-72. [PMID: 35969584 DOI: 10.1080/14764172.2022.2112231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Genital aesthetic procedures have increased in popularity among women and men. Many clinicians tried to expand the application of fill injection by using it for genital aesthetic injection. However, this procedure is not so safe as imagined and may lead to a fatal complication of pulmonary embolism. This article summarizes the clinical manifestations and proposed mechanism of the filler-induced non-thrombotic pulmonary embolism (FINTPE) cases. A literature review was performed with the search keywords including "genital aesthetic injection, vaginal injection, vaginoplasty, vaginal tightening, penile augmentation, penis injection, hyaluronic acid, fat grafting, pulmonary embolism, alveolar hemorrhage, hypoxemia, and dyspnea." Among the 14 cases from 11 articles enrolled, 12 patients were female, and two were male. Eight patients received silicone injection, followed by two received fat grafting and hyaluronic acid injection, respectively. All the female patients had one single injection site, including 11 cases for the vaginal wall and one for G-spot, while all the male patients received injections into the penis and scrotum. The main symptoms were dyspnea and chest pain. Almost 60% of FINTPE patients presented respiratory disorders within 12 hours post-operation. Treatment includes oxygen therapy, corticosteroids, and anticoagulation. Five patients improved with an average of 14.6-day treatment, and seven died due to organ failures. Genital aesthetic filler injections are experimental procedures without being strictly reviewed or approved. As a severe complication following these procedures, FINTPE requires cautious performance, careful prevention, timely identification, and treatment to decrease its incidence and mortality.
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Affiliation(s)
- Hayson Chenyu Wang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xiao Long
- Department of Plastic Surgery, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Mohsin M, Farooq MU, Akhtar W, Mustafa W, Rehman TU, Malik J, Zahid T. Echocardiography in a critical care unit: A contemporary review. Expert Rev Cardiovasc Ther 2022; 20:55-63. [PMID: 35098852 DOI: 10.1080/14779072.2022.2036124] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Echocardiography is a rapid, noninvasive, and complete cardiac assessment tool for patients with hemodynamic instability. This review provides an overview of the evidence for current practices in critical care units (CCUs), incorporating the use of echocardiography in different etiologies of shock. AREAS COVERED : Relevant articles were extracted after searching on databases by two reviewers and incorporated in this review in a narrative style. EXPERT OPINION : In an acute scenario, a basic echocardiographic study yields prompt diagnosis, allowing for the initiation of treatment. The most common pathologies in shocked patients are identified promptly using two-dimensional (2D) and M-mode echocardiography. A more comprehensive assessment can follow after patients have been stabilized. There are four types of shock: (i) cardiogenic shock, (ii) hypovolemic shock, (iii) obstructive shock, and (iv) septic shock. All of them can be readily identified by echocardiography. As echocardiography is increasingly being used in an intensive care setting, its applications and evidence base should be expanded by randomized controlled trials to demonstrate patient outcomes in critical care.
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Affiliation(s)
- Muhammad Mohsin
- Department of Interventional Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, 46000, Pakistan
| | - Muhammad Umar Farooq
- Department of Interventional Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, 46000, Pakistan
| | - Waheed Akhtar
- Department of Cardiology, Abbas Institute of Medical Sciences, Muzaffarabad, 13190, Pakistan
| | - Waqar Mustafa
- Department of Cardiology, Abbas Institute of Medical Sciences, Muzaffarabad, 13190, Pakistan
| | - Tanzeel Ur Rehman
- Department of Cardiology, Benazir Bhutto Hospital, Rawalpindi, 46000, Pakistan
| | - Jahanzeb Malik
- Department of Interventional Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, 46000, Pakistan
| | - Taimoor Zahid
- Department of Medicine, Warwick Hospital, Warwickshire, United Kingdom
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Romeu-Prieto JM, Sánchez Casado M, Rodríguez Blanco ML, Ciampi-Dopazo JJ, Sánchez-Carretero MJ, García-López JJ, Lanciego-Pérez C. Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk. Med Clin (Barc) 2021; 158:401-405. [PMID: 34384613 DOI: 10.1016/j.medcli.2021.04.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND PURPOSE The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE). METHODS We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S' wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality. RESULTS In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S' wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase. CONCLUSIONS Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis.
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Santens B, Van De Bruaene A, De Meester P, D'Alto M, Reddy S, Bernstein D, Koestenberger M, Hansmann G, Budts W. Diagnosis and treatment of right ventricular dysfunction in congenital heart disease. Cardiovasc Diagn Ther 2020; 10:1625-1645. [PMID: 33224777 DOI: 10.21037/cdt-20-370] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Right ventricular (RV) function is important for clinical status and outcomes in children and adults with congenital heart disease (CHD). In the normal RV, longitudinal systolic function is the major contributor to global RV systolic function. A variety of factors contribute to RV failure including increased pressure- or volume-loading, electromechanical dyssynchrony, increased myocardial fibrosis, abnormal coronary perfusion, restricted filling capacity and adverse interactions between left ventricle (LV) and RV. We discuss the different imaging techniques both at rest and during exercise to define and detect RV failure. We identify the most important biomarkers for risk stratification in RV dysfunction, including abnormal NYHA class, decreased exercise capacity, low blood pressure, and increased levels of NTproBNP, troponin T, galectin-3 and growth differentiation factor 15. In adults with CHD (ACHD), fragmented QRS is independently associated with heart failure (HF) symptoms and impaired ventricular function. Furthermore, we discuss the different HF therapies in CHD but given the broad clinical spectrum of CHD, it is important to treat RV failure in a disease-specific manner and based on the specific alterations in hemodynamics. Here, we discuss how to detect and treat RV dysfunction in CHD in order to prevent or postpone RV failure.
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Affiliation(s)
- Béatrice Santens
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Alexander Van De Bruaene
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Pieter De Meester
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
| | - Michele D'Alto
- Department of Cardiology, University "L. Vanvitelli" - Monaldi Hospital, Naples, Italy
| | - Sushma Reddy
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | - Daniel Bernstein
- Department of Pediatrics (Cardiology), Stanford University, California, United States of America
| | | | - Georg Hansmann
- Department of Pediatric Cardiology and Critical care, Hannover Medical School, Hannover, Germany
| | - Werner Budts
- Congenital and Structural Cardiology, University Hospitals Leuven, Leuven, Belgium.,Department of Cardiovascular Sciences, Catholic University Leuven, Leuven, Belgium
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Echocardiographic Predictors of Long-Term Mortality in Patients Presenting With Acute Pulmonary Embolism. Am J Cardiol 2019; 124:285-291. [PMID: 31101322 DOI: 10.1016/j.amjcard.2019.04.039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/01/2019] [Accepted: 04/05/2019] [Indexed: 11/21/2022]
Abstract
Pulmonary embolism (PE) is associated with a high mortality; whether echocardiographic evaluation at presentation predicts long-term adverse outcomes is of importance. We sought to determine if a composite of routinely obtained echocardiographic parameters could determine long-term adverse events in PE patients. Right ventricular (RV) size and function and right atrial (RA) size were retrospectively evaluated in 233 consecutive PE patients with an inpatient echocardiogram, and compared with 70 healthy controls; mortality at 3 years was confirmed. PE patients had increased RV size (RV parasternal long-axis diameter [RVPLAX] and RV end-diastolic volume [p < 0.001 for both]) and RA area (p < 0.001). RV function was reduced in PE patients (RV fractional area change and RV ejection fraction [p <0.001 for both]). Peak tricuspid regurgitation (TR) velocity was higher in the PE group. At follow-up (3.0 ± 2.1 years), 61 patients died; multivariable analysis demonstrated RVPLAX diameter >37 mm (hazard ratio [HR] 2.3, 95% confidence interval [CI] 1.3 to 4.2; p = 0.005), RA area >20 cm2 (HR 2.0, 95% CI 1.1 to 3.5; p = 0.016), and TR velocity >2.9 ms-1 (HR 1.9, 95% CI 1.1 to 3.4; p = 0.021), were independent echocardiographic predictors of mortality. Patients with all 3 "risk markers" had ∼17-fold increased mortality compared with those with no "risk markers" (HR 16.9, 95% CI 6.1 to 47.2; p < 0.001). In conclusion, a composite of routinely collected echocardiographic parameters, namely an enlarged RA and RV (RVPLAX diameter), and TR velocity, were independent predictors of mortality in PE patients, with an exponential increase in mortality when all 3 parameters were significantly altered. Prospective validation is required to confirm these preliminary observations.
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