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Lin TW, Tsai MT, Hu YN, Wang YC, Wen JS, Wu HY, Luo CY, Roan JN. Simultaneous Thrombolysis and Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Emboli. Ann Thorac Surg 2020; 111:923-929. [PMID: 32738223 DOI: 10.1016/j.athoracsur.2020.05.155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/21/2020] [Accepted: 05/23/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been used in patients with circulatory collapse or extremely unstable hemodynamics caused by acute massive pulmonary embolism (PE). The effectiveness of simultaneous thrombolytic therapy has been rarely investigated in these patients after being stabilized with ECMO. METHODS From January 2008 to December 2018 consecutive patients with acute massive PE requiring ECMO supported in a tertiary medical center were included for retrospective analysis. RESULTS Thirteen patients with PE underwent ECMO implantation and received subsequent thrombolytic therapy as a definite treatment for PE. All patients survived their ECMO courses to a successful decannulation, with a mean ECMO support duration of 6.23 ± 4.69 days. Eleven patients (84.62%) survived to hospital discharge. All survivors were alive during follow-up, although 2 patients (18.2%) had permanent dysfunctional neurologic complications. Major bleeding complications occurred in 4 patients (30.77%), whereas no patient had intracranial hemorrhage. Systemic thrombolysis showed comparable outcomes of catheter-directed thrombolysis in our patients who underwent ECMO. CONCLUSIONS Thrombolysis-based therapeutic strategy under ECMO could be a relatively safe and effective definitive treatment for patients with acute massive PE, even for those who were resuscitated. Bleeding complications remain a major concern and should be monitored and managed immediately.
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Affiliation(s)
- Ting-Wei Lin
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Chen Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jih-Sheng Wen
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Hsuan-Yin Wu
- Division of Cardiovascular Surgery, Department of Surgery, E-DA Hospital and College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Chwan-Yau Luo
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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Chang HY, Chang WT, Chen PW, Lin CC, Hsu CH. Pulmonary thromboembolism with computed tomography defined chronic thrombus is associated with higher mortality. Pulm Circ 2020; 10:2045894020905510. [PMID: 32426110 PMCID: PMC7222268 DOI: 10.1177/2045894020905510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 01/16/2020] [Indexed: 11/15/2022] Open
Abstract
With the advancement of computed tomography pulmonary angiography, differentiating between acute and chronic thrombus in pulmonary embolism has become more feasible. However, whether pulmonary embolism with chronic thrombus contributes to a higher mortality than pulmonary embolism with acute thrombus remains undetermined. Additionally, the clinical features of patients with chronic thrombus are largely unknown. Herein, we aimed to investigate the incidence and outcomes of patients with pulmonary embolism and chronic thrombus. This retrospective study included patients with pulmonary embolism from 2008 to 2016 at National Cheng Kung University Hospital. After excluding patients with tumor emboli or other etiologies and a lack of computed tomography images, we identified 205 patients with acute thrombus and 58 patients with chronic thrombus. Patients with chronic thrombus initially presented mainly with dyspnea, and the etiology was not related to recent surgery. Patients with chronic thrombus had a significantly higher incidence of elevated right ventricular systolic pressure detected by echocardiography and a higher incidence of subsequent events due to residual pulmonary embolism. Despite no differences in clinically recurrent pulmonary embolism, patients with chronic thrombus presented with a higher risk of all-cause and pulmonary embolism-related mortality than patients with acute thrombus. Chronic thrombus (hazard ratio: 2.03, p = 0.03), simplified pulmonary embolism severity index, anticoagulant use, and body mass index were the independent factors for all-cause mortality. Our findings suggest that using computed tomography pulmonary angiography for identifying patients with pulmonary embolism and chronic thrombus, which was associated with a higher risk of mortality, is pivotal for early intervention in addition to anticoagulant use.
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Affiliation(s)
- Hsien-Yuan Chang
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Wei-Ting Chang
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan.,Department of Biotechnology, Southern Taiwan University of Science and Technology, Tainan, Taiwan
| | - Po-Wei Chen
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Chan Lin
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chih-Hsin Hsu
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.,Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, Dou-Liou Branch, Yunlin, Taiwan
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Rosovsky R, Zhao K, Sista A, Rivera‐Lebron B, Kabrhel C. Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions. Res Pract Thromb Haemost 2019; 3:315-330. [PMID: 31294318 PMCID: PMC6611377 DOI: 10.1002/rth2.12216] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 04/09/2019] [Indexed: 12/20/2022] Open
Abstract
Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.
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Affiliation(s)
- Rachel Rosovsky
- Division of Hematology & OncologyDepartment of MedicineMassachusetts HospitalBostonMassachusetts
| | - Ken Zhao
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Akhilesh Sista
- Division of Interventional RadiologyDepartment of RadiologyNew York University Langone Medical CenterNew YorkNew York
| | - Belinda Rivera‐Lebron
- Division of Pulmonary, Allergy and Critical Care MedicineDepartment of MedicineUniversity of PittsburghPittsburghPennsylvania
| | - Christopher Kabrhel
- Center for Vascular EmergenciesDepartment of Emergency MedicineMassachusetts General HospitalBostonMassachusetts
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