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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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2
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Singh G, Bamba H, Inban P, Chandrasekaran SH, Priyatha V, John J, Prajjwal P. The prognostic significance of pro-BNP and heart failure in acute pulmonary embolism: A systematic review. Dis Mon 2024:101783. [PMID: 38955637 DOI: 10.1016/j.disamonth.2024.101783] [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: 07/04/2024]
Abstract
Pulmonary embolism (PE) is the third most common type of cardiovascular disease and carries a high mortality rate of 30% if left untreated. Although it is commonly known that individuals who suffer heart failure (HF) are more likely to experience a pulmonary embolism, little is known concerning the prognostic relationship between acute PE and HF. This study aims to evaluate the prognostic usefulness of heart failure and pro-BNP in pulmonary embolism cases. A scientific literature search, including PubMed, Medline, and Cochrane reviews, was used to assess and evaluate the most pertinent research that has been published. The findings showed that increased N-terminal brain natriuretic peptide (NT-proBNP) levels could potentially identify pulmonary embolism patients with worse immediate prognoses and were highly predictive of all-cause death. Important prognostic information can be obtained from NT-proBNP and Heart-type Fatty Acid Binding Proteins (H-FABP) when examining individuals with PE. The heart, distal tubular cells of the renal system, and skeletal muscle are where H-FABP is primarily found, with myocardial cells having the highest concentration. Recent studies have indicated that these biomarkers may also help assess the severity of PE and its long-term risk.
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Affiliation(s)
- Gurmehar Singh
- Government Medical College and Hospital, Chandigarh, India
| | - Hyma Bamba
- Government Medical College and Hospital, Chandigarh, India
| | - Pugazhendi Inban
- Internal Medicine, St. Mary's General Hospital and Saint Clare's Health, NY, USA.
| | | | | | - Jobby John
- Dr. Somervell Memorial CSI Medical College and Hospital Karakonam, Trivandrum, India
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3
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Villalba L, Deen R, Tonson-Older B, Costello C. Single-session catheter-directed lysis using adjunctive clot fragmentation with power pulse spray only is a fast, safe, and effective option for acute pulmonary embolism. J Vasc Surg Venous Lymphat Disord 2024; 12:101899. [PMID: 38677551 DOI: 10.1016/j.jvsv.2024.101899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/11/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVE Single-session, catheter-directed thrombolysis (CDT) with adjunctive power pulse spray (PPS) only, without thrombectomy, was evaluated for its safety and effectiveness. We performed a single-center, retrospective analysis of prospectively collected data. METHODS Patients with high-risk or intermediate-risk pulmonary embolism (PE) who met the inclusion criteria and underwent a single session of CDT-PPS were included in the study. The primary outcomes assessed were technical and clinical success and major adverse events. Secondary outcomes included effectiveness based on pre- and postintervention clinical examination, radiographic findings, and reversal of right ventricular dysfunction at 48 hours and 4 weeks after discharge on echocardiography and computed tomography pulmonary angiography. The length of stay in the intensive care unit and overall admission were also analyzed. A return to premorbid exercise tolerance was evaluated at 12 months after the procedure. RESULTS Between May 2016 and January 2023, 104 patients at the Wollongong Hospital were diagnosed with high- or intermediate-risk PE and underwent CDT-PPS. Of the 104 patients, 49 (47%) were considered to have high-risk PE and 55 (53%) intermediate-risk PE. Eleven patients (11%) had absolute contraindications and 49 patients (47%) had relative contraindications to systemic thrombolysis. Technical success was achieved in 102 patients (98%). Survival was 99% at 48 hours, 96% at 4 weeks, and 91% at 12 months. At 4 weeks, echocardiography showed 98% of patients had no evidence of right heart dysfunction, and computed tomography pulmonary angiography showed complete resolution of PE in 72%. There were no major adverse events at 48 hours. The median intensive care unit length of stay was 1 day, and the overall length of stay was 6 days. At 12 months, 96% had returned to their premorbid status. CONCLUSIONS The CDT-PPS technique is fast, safe, and effective in the treatment of high- and intermediate-risk PE, even in patients with a high bleeding risk, and should be considered as first-line management when the skills and resources are available. Further multicenter prospective studies are needed to corroborate these results.
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Affiliation(s)
- Laurencia Villalba
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Intensive Care Unit, Department of Vascular Surgery, Vascular Care Centre, Wollongong, New South Wales, Australia.
| | - Raeed Deen
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Brendan Tonson-Older
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Cartan Costello
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
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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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5
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Robinson H, Anstey M, Litton E, Ho KM, Jacques A, Rathore K, Yap T, Lucas M, Worthy L, Tan JL, Yeoh M, Yau HC, Robinson K, Mudie J, Hennelly G, Wibrow B. Long-Term Echocardiographic and Clinical Outcomes After Invasive and Non-Invasive Therapies for Sub-Massive and Massive Acute Pulmonary Embolism. Heart Lung Circ 2024:S1443-9506(24)00197-5. [PMID: 38942622 DOI: 10.1016/j.hlc.2024.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 06/30/2024]
Abstract
AIM Acute pulmonary embolism (PE) is a significant cause of mortality in the hospital setting. The objective of this study was to outline the long-term outcomes after surgical and non-surgical management for patients with massive and submassive PE. METHODS Population cohort observational study evaluating all patients who presented to three tertiary hospitals in the state of Western Australia with access to cardiothoracic services over 5 years (2013-2018). Reviewed notes of all patients as well as radiology, linked mortality data and all available echocardiography studies at the primary hospital. RESULTS In total, 245 patients were identified, of which 41 received surgical management and 204 non-surgical management; demographic data was similar. Clinically, the surgical group had higher rates of shock requiring vasopressors, severe bradycardia, or cardiopulmonary resuscitation prior to intervention. The 28-day mortality was not statistically significantly different between the surgical embolectomy group (2/41 [4.2%]) and the non-surgical group (17/201 [8.3%]) (p=0.382). There was no difference in 12-month mortality, including when this was adjusted for vasopressors, right ventricular (RV) strain, troponin, and brain natriuretic peptide. In the massive PE sub-group, 28-day mortality was not significantly different: 2/29 (6.9%) surgical group vs 7/34 (20.2%) non-surgical group (p=0.064). Higher rates of severe RV impairment and dilatation were present in the surgical group. All patients with available echocardiography studies at outpatient follow-up returned to normal or mild RV impairment. CONCLUSION Patients who presented with massive or submassive PE had similar outcomes whether treated with surgical or non-surgical management. Surgical embolectomy is a safe option in a cardiothoracic centre setting.
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Affiliation(s)
- Hayley Robinson
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Curtin School of Public Health, Curtin University, Bentley, WA, Australia
| | - Edward Litton
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Department of Intensive Care, St John of God Healthcare, Subiaco, WA, Australia
| | - Kwok M Ho
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia; Medical School and School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA, Australia; Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Angela Jacques
- Institute of Health Research, University of Notre Dame Australia, Fremantle, WA, Australia; Department of Research, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Kaushalendra Rathore
- Department of Cardiothoracics, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Timothy Yap
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Monique Lucas
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Laura Worthy
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Jo-Lynn Tan
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Matthew Yeoh
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Ho-Cing Yau
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
| | - Kieran Robinson
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Jess Mudie
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Gavin Hennelly
- Department of Intensive Care, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Bradley Wibrow
- Department of Intensive Care, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Department of Medicine and Pharmacology, University of Western Australia, Crawley, WA, Australia.
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Huang T, Ni C, Ding W, Jin Y, Deng X, Jiang X, Chen Z, Hong X. Risk factors of moderate-severe Post-thrombotic syndrome within 2 years in patients with subacute thrombosis: A case-control study. J Vasc Surg Venous Lymphat Disord 2024:101933. [PMID: 38906457 DOI: 10.1016/j.jvsv.2024.101933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/31/2024] [Accepted: 06/09/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To study the risk factors influencing the occurrence of moderate-severe post-thrombotic syndrome (PTS) within 2 years in patients with subacute lower extremity deep vein thrombosis (DVT). METHODS Seventy patients who developed moderate-severe PTS within 2 years after subacute lower extremity DVT from June 2018 to June 2022 were retrospectively selected as the case group. They were matched 1:1 by sex and age (±5 years) with 70 patients who did not develop moderate- severe PTS during the same follow-up period as the control group. Multiple logistic regression, stratified analysis, and interaction analyses were used to explore the risk factors for moderate-severe PTS. RESULTS The multiple logistic regression model showed that patients with iliofemoral vein thrombosis had a significantly increased risk of developing moderate-severe PTS within 2 years. Patients who underwent intraluminal intervention treatment during hospitalization had a significantly reduced risk. The odds ratios (ORs) were 4.000 (95%CI 1.597∼10.016) for the femoral-popliteal vein thrombosis and 0.262 (95%CI 0.106∼0.647) for the anticoagulation treatment group. The stratified analysis showed that intraluminal intervention treatment was a protective factor against moderate-severe PTS within 2 years across different strata of hypertension, thrombus type, BMI, duration of anticoagulation, and wearing compression stockings. Additionally, there was an interaction between thrombus type and treatment method, with intraluminal intervention treatment having a more pronounced effect on preventing moderate-severe PTS in patients with iliofemoral vein thrombosis. CONCLUSION Iliofemoral vein thrombosis is a risk factor for the development of moderate-severe PTS within 2 years in patients with subacute lower extremity DVT. Intraluminal intervention treatment can reduce the risk of moderate-severe PTS, especially in patients with iliofemoral vein thrombosis.
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Affiliation(s)
- Tianan Huang
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China
| | - Caifang Ni
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China
| | - Wenbin Ding
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China
| | - Yonghai Jin
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, 215006, China
| | - Xiaowen Deng
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China
| | - Xiaodong Jiang
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China
| | - Zhuo Chen
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China
| | - Xin Hong
- Department of Interventional Radiology, The Affiliated Hospital 2 of Nantong University, Nantong, Jiangsu, 226001, China.
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Zeng W, Gao Y, Wang Q, Chi J, Zhu Z, Diao Q, Li X, Wang Z, Qu M, Shi Y. Preliminary clinical analysis and pathway study of S100A8 as a biomarker for the diagnosis of acute deep vein thrombosis. Sci Rep 2024; 14:13298. [PMID: 38858401 PMCID: PMC11164926 DOI: 10.1038/s41598-024-61728-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/08/2024] [Indexed: 06/12/2024] Open
Abstract
Herein, we aimed to identify blood biomarkers that compensate for the poor specificity of D-dimer in the diagnosis of deep vein thrombosis (DVT). S100A8 was identified by conducting protein microarray analysis of blood samples from patients with and without DVT. We used ELISA to detect S100A8, VCAM-1, and ICAM-1 expression levels in human blood and evaluated their correlations. Additionally, we employed human recombinant protein S100A8 to induce human umbilical vein endothelial cells and examined the role of the TLR4/MAPK/VCAM-1 and ICAM-1 signaling axes in the pathogenic mechanism of S100A8. Simultaneously, we constructed a rat model of thrombosis induced by inferior vena cava stenosis and detected levels of S100A8, VCAM-1, and ICAM-1 in the blood of DVT rats using ELISA. The associations of thrombus tissue, neutrophils, and CD68-positive cells with S100A8 and p38MAPK, TLR4, and VCAM-1 expression levels in vein walls were explored. The results revealed that blood S100A8 was significantly upregulated during the acute phase of DVT and activated p38MAPK expression by combining with TLR4 to enhance the expression and secretion of VCAM-1 and ICAM-1, thereby affecting the occurrence and development of DVT. Therefore, S100A8 could be a potential biomarker for early diagnosis and screening of DVT.
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Affiliation(s)
- Wenjie Zeng
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Yangyang Gao
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Qitao Wang
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Junyu Chi
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Ziyan Zhu
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Qingfei Diao
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Xin Li
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Zhen Wang
- Graduate School, Hebei North University, Zhangjiakou, 075000, Hebei, China
| | - Ming Qu
- Vascular Gland Surgery, The First Affiliated Hospital of Hebei North University, Zhangjiakou, Hebei, China.
| | - Yongquan Shi
- Department of Clinical Laboratory Center, Shandong Second Provincial General Hospital, Jinan, Shandong, China
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8
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Raghubeer N, Lahri S, Hendrikse C. The value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism: A cross sectional analysis. Afr J Emerg Med 2024; 14:65-69. [PMID: 38425642 PMCID: PMC10899042 DOI: 10.1016/j.afjem.2024.01.004] [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] [Received: 09/18/2023] [Revised: 01/23/2024] [Accepted: 01/25/2024] [Indexed: 03/02/2024] Open
Abstract
Introduction Pulmonary embolism (PE) is a significant global cause of mortality, ranking third after myocardial infarction and stroke. ECG findings may play a valuable role in the prognostication of patients with PE, with various ECG abnormalities proving to be reasonable predictors of haemodynamic decompensation, cardiogenic shock, and even mortality. This study aims to assess the value of electrocardiography in predicting inpatient mortality in patients with acute pulmonary embolism, as diagnosed with computed tomography pulmonary angiogram. Method This study was a cross sectional analysis based at Tygerberg Hospital, Cape Town, South Africa. Eligible patients were identified from all CT-PA performed between 1 January 2017 and 31 December 2019 (2 years). The ECGs were independently screened by two blinded emergency physicians for predetermined signs that are associated with right heart strain and higher pulmonary artery pressures, and these findings were analysed to in-hospital mortality. Results Of the included 81 patients, 61 (75 %) were female. Of the 41 (51 %) patients with submassive PE and 8 (10 %) with massive PE, 7 (17 %) and 3 (38 %) suffered inpatient mortality (p = 0.023) respectively. Univariate ECG analysis revealed that complete right bundle branch block (OR, 8.6; 95 % CI, 1.1 to 69.9; p = 0.044) and right axis deviation (OR, 5.6; 95 % CI, 1.4 to 22.4; p = 0.015) were significant predictors of inpatient mortality. Conclusion Early identification of patients with pulmonary embolism at higher risk of clinical deterioration and in-patient mortality remains a challenge. Even though no clinical finding or prediction tool in isolation can reliably predict outcomes in patients with pulmonary embolism, this study demonstrated two ECG findings at presentation that were associated with a higher likelihood of inpatient mortality. This single-centre observational study with a small sample precludes concrete conclusions and a large follow-up multi-centre study is advised.
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Affiliation(s)
- Nishen Raghubeer
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
| | - Sa'ad Lahri
- Division of Emergency Medicine, University of Stellenbosch, Stellenbosch, South Africa
| | - Clint Hendrikse
- Division of Emergency Medicine, University of Cape Town, Cape Town, South Africa
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Morgan CT, Saha SP. A Brief Historical Perspective on Pulmonary Embolism. Int J Angiol 2024; 33:71-75. [PMID: 38846993 PMCID: PMC11152623 DOI: 10.1055/s-0044-1782603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow's first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.
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Affiliation(s)
- Clinton T. Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
| | - Sibu P. Saha
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Kentucky
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10
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Aghayev A, Hinnerichs M, Wienke A, Meyer HJ, Surov A. Epicardial adipose tissue as a prognostic marker in acute pulmonary embolism. Herz 2024; 49:219-223. [PMID: 37847316 PMCID: PMC11136740 DOI: 10.1007/s00059-023-05210-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 09/10/2023] [Accepted: 09/11/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND Epicardial adipose tissue (EAT) has been established as a quantitative imaging biomarker associated with disease severity in coronary heart disease. Our aim was to use this prognostic marker derived from computed tomography pulmonary angiography (CTPA) for the prediction of mortality and prognosis in patients with acute pulmonary embolism. METHODS The clinical database was retrospectively screened for patients with acute pulmonary embolism between 2015 and 2021. Overall, 513 patients (216 female, 42.1%) were included in the analysis. The study end-point was 30-day mortality. Epicardial adipose tissue was measured on the diagnostic CTPA in a semiquantitative manner. The volume and density of EAT were measured for every patient. RESULTS Overall, 60 patients (10.4%) died within the 30-day observation period. The mean EAT volume was 128.3 ± 65.0 cm3 in survivors and 154.6 ± 84.5 cm3 in nonsurvivors (p = 0.02). The density of EAT was -79.4 ± 8.3 HU in survivors and -76.0 ± 8.4 HU in nonsurvivors (p = 0.86), and EAT density was associated with 30-day mortality (odds ratio [OR] = 1.07; 95% confidence interval [CI]: 1.03; 1.1, p < 0.001) but did not remain statistically significant in multivariable analysis. No association was identified between EAT volume and 30-day mortality (OR = 1.0; 95% CI: 1.0; 1.0, p = 0.48). CONCLUSION There might be an association between EAT density and mortality in patients with acute pulmonary embolism. Further studies are needed to elucidate the prognostic relevance of EAT parameters in patients with acute pulmonary embolism.
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Affiliation(s)
- Anar Aghayev
- Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
| | - Mattes Hinnerichs
- Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
| | - Andreas Wienke
- Institute of Medical Epidemiology, Biostatistics, and Informatics, Martin-Luther-University Halle-Wittenberg, Halle, Germany
| | - Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University of Leipzig, Leipzig, Germany.
| | - Alexey Surov
- Department of Radiology and Nuclear Medicine, Otto von Guericke University, Magdeburg, Germany
- Ruhr-University-Bochum, Department of Radiology, Neuroradiology and Nuclear Medicine, Johannes Wesling University Hospital, Minden, Germany
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11
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Visconti L, Celi A, Carrozzi L, Tinelli C, Crocetti L, Daviddi F, De Caterina R, Madonna R, Pancani R. Inferior vena cava filters: Concept review and summary of current guidelines. Vascul Pharmacol 2024; 155:107375. [PMID: 38663572 DOI: 10.1016/j.vph.2024.107375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/05/2024]
Abstract
Anticoagulation is the first-line approach in the prevention and treatment of pulmonary embolism. In some instances, however, anticoagulation fails, or cannot be administered due to a high risk of bleeding. Inferior vena cava filters are metal alloy devices that mechanically trap emboli from the deep leg veins halting their transit to the pulmonary circulation, thus providing a mechanical alternative to anticoagulation in such conditions. The Greenfield filter was developed in 1973 and was later perfected to a model that could be inserted percutaneously. Since then, this model has been the reference standard. The current class I indication for this device includes absolute contraindication to anticoagulants in the presence of acute thromboembolism and recurrent thromboembolism despite adequate therapy. Additional indications have been more recently proposed, due to the development of removable filters and of progressively less invasive techniques. Although the use of inferior vena cava filters has solid theoretical advantages, clinical efficacy and adverse event profile are still unclear. This review analyzes the most important studies related to such devices, open issues, and current guideline recommendations.
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Affiliation(s)
- Luca Visconti
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Ospedale "Sacro Cuore di Gesù" Gallipoli, Azienda Sanitaria Locale Lecce, Italy
| | - Alessandro Celi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
| | - Laura Carrozzi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy; Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Camilla Tinelli
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Laura Crocetti
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Interventional Radiology Unit, University of Pisa, Pisa, Italy
| | - Francesco Daviddi
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Interventional Radiology Unit, University of Pisa, Pisa, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Cardiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Rosalinda Madonna
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa and Cardiology Unit, Cardio-Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Roberta Pancani
- Pulmonary Unit, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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12
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McGuire WC, Sullivan L, Odish MF, Desai B, Morris TA, Fernandes TM. Management Strategies for Acute Pulmonary Embolism in the ICU. Chest 2024:S0012-3692(24)00675-5. [PMID: 38830402 DOI: 10.1016/j.chest.2024.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 04/11/2024] [Accepted: 04/15/2024] [Indexed: 06/05/2024] Open
Abstract
TOPIC IMPORTANCE Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with high-risk acute PE (defined by systemic hypotension) and intermediate high-risk acute PE (defined by the absence of systemic hypotension, but the presence of numerous other concerning clinical and imaging features), intensive care often is necessary. Initial management strategies should focus on optimization of right ventricle (RV) function while decisions about advanced interventions are being considered. REVIEW FINDINGS We reviewed the existing literature of various vasoactive agents, IV fluids and diuretics, and pulmonary vasodilators in both animal models and human trials of acute PE. We also reviewed the potential complications of endotracheal intubation and positive pressure ventilation in acute PE. Finally, we reviewed the data of venoarterial extracorporeal membrane oxygenation (ECMO) use in acute PE. The above interventions are discussed in the context of the underlying pathophysiologic features of acute RV failure in acute PE with corresponding illustrations. SUMMARY Norepinephrine is a reasonable first choice for hemodynamic support with vasopressin as an adjunct. IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present. Fluids should be given only if concern exists for hypovolemia and absence of RV dilatation. Supplemental oxygen administration should be considered even without hypoxemia. Positive pressure ventilation should be avoided if possible. venoarterial ECMO cannulation should be implemented early if ongoing deterioration occurs despite these interventions.
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Affiliation(s)
- W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA.
| | - Lauren Sullivan
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Mazen F Odish
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Brinda Desai
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Timothy A Morris
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
| | - Timothy M Fernandes
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California, San Diego, La Jolla, CA
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13
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Mohammed AQI, Berman L, Staroselsky M, Wenn P, Hai O, Makaryus AN, Zeltser R. Clinical Presentation and Risk Stratification of Pulmonary Embolism. Int J Angiol 2024; 33:82-88. [PMID: 38846996 PMCID: PMC11152639 DOI: 10.1055/s-0044-1786878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Pulmonary embolism (PE) presents with a spectrum of symptoms, ranging from asymptomatic cases to life-threatening events. Common symptoms include sudden dyspnea, chest pain, limb swelling, syncope, and hemoptysis. Clinical presentation varies based on thrombus burden, demographics, and time to presentation. Diagnostic evaluation involves assessing symptoms, physical examination findings, and utilizing laboratory tests, including D-dimer. Risk stratification using tools like Wells score, Pulmonary Embolism Severity Index, and Hestia criteria aids in determining the severity of PE. PE is categorized based on hemodynamic status, temporal patterns, and anatomic locations of emboli to guide in making treatment decisions. Risk stratification plays a crucial role in directing management strategies, with elderly and comorbid individuals at higher risk. Early identification and appropriate risk stratification are essential for effective management of PE. As we delve into this review article, we aim to enhance the knowledge base surrounding PE, contributing to improved patient outcomes through informed decision-making in clinical practice.
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Affiliation(s)
| | - Lorin Berman
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Mark Staroselsky
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Peter Wenn
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Ofek Hai
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
| | - Amgad N. Makaryus
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Roman Zeltser
- Department of Cardiology, Nassau University Medical Center, East Meadow, NY
- Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
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14
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Hobohm L, Farmakis IT, Duerschmied D, Keller K. The Current Evidence of Pulmonary Embolism Response Teams and Their Role in Future. Hamostaseologie 2024; 44:172-181. [PMID: 38471662 DOI: 10.1055/a-2232-5395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Acute pulmonary embolism (PE) remains a critical medical condition requiring prompt and accurate management. The introduction and growing significance of pulmonary embolism response teams (PERT), also termed EXPERT-PE teams, signify a paradigm shift toward a collaborative, multidisciplinary approach in managing this complex entity. As the understanding of acute PE continues to evolve, PERTs stand as a linkage of optimized care, offering personalized and evidence-based management strategies for patients afflicted by this life-threatening condition. The evolving role of PERTs globally is evident in their increasing integration into the standard care pathways for acute PE. These teams have demonstrated benefits such as reducing time to diagnosis and treatment initiation, optimizing resource utilization, and improving patient outcomes.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
| | - Ioannis T Farmakis
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Hemostasis, and Medical Intensive Care, University Medical Centre Mannheim, Medical Faulty Mannheim, University of Heidelberg, Germany
- European Center for AngioScience (ECAS), German Center for Cardiovascular Research (DZHK) partner site Heidelberg/ Mannheim, and Centre for Cardiovascular Acute Medicine Mannheim (ZKAM), Medical Centre Mannheim, Heidelberg University, Germany
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), and DZHK Standort Rhein-Main, Mainz, Germany
- Department of Sports Medicine, Internal Medicine VII, Medical Clinic, University Hospital, Heidelberg, Germany
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15
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Lei K, DiCaro MV, Tak N, Turnbull S, Abdallah A, Cyrus T, Tak T. Contemporary Management of Pulmonary Embolism: Review of the Inferior Vena Cava filter and Other Endovascular Devices. Int J Angiol 2024; 33:112-122. [PMID: 38846989 PMCID: PMC11152642 DOI: 10.1055/s-0044-1785231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
Inferior vena cava (IVC) filters and endovascular devices are used to mitigate the risk of pulmonary embolism in patients presenting with lower extremity venous thromboembolism in whom long-term anticoagulation is not a good option. However, the efficacy and benefit of these devices remain uncertain, and controversies exist. This review focuses on the current use of IVC filters and other endovascular therapies in clinical practice. The indications, risks, and benefits are discussed based on current data. Further research and randomized controlled trials are needed to characterize the patient population that would benefit most from these interventional therapies.
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Affiliation(s)
- KaChon Lei
- Department of Cardiovascular Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
| | - Michael V. DiCaro
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
| | - Nadia Tak
- Research Associate, University of Minnesota - Twin Cities, Minneapolis, Minnesota
| | - Scott Turnbull
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
| | - Ala Abdallah
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
| | - Tillman Cyrus
- Department of Cardiovascular Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
- Department of Cardiovascular Medicine, Veteran Affairs Medical Center, North Las Vegas, Nevada
| | - Tahir Tak
- Department of Cardiovascular Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
- Department of Internal Medicine, Kirk Kerkorian SOM at the University of Nevada Las Vegas, Las Vegas, Nevada
- Department of Cardiovascular Medicine, Veteran Affairs Medical Center, North Las Vegas, Nevada
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16
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Hou W, Fang D, Yin S, Deng Y, Zhang J, Wang S, Liu L, Kong J, Huang M, Zhang X, Dai B, Feng X. Effectiveness and Safety of Early Versus Routine Switching from Low-Molecular-Weight Heparin to Maintenance Therapy of Rivaroxaban for Acute Iliofemoral Vein Thrombosis: A Retrospective Cohort Study. Ann Vasc Surg 2024; 106:152-161. [PMID: 38815910 DOI: 10.1016/j.avsg.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/06/2024] [Accepted: 03/06/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND The anticoagulation strategy of switching to rivaroxaban after 1 week of initial low-molecular-weight heparin (LMWH) therapy is recommended by a guideline for the treatment of acute iliofemoral deep vein thrombosis (DVT). However, the initial rivaroxaban dose in the switching strategy, as well as the effectiveness and safety of the early switching (less than 1 week) to rivaroxaban, remain inadequately substantiated. We aimed to evaluate the effectiveness and safety of early switching from LMWH to maintenance therapy of rivaroxaban (20 mg once daily) for acute iliofemoral DVT. METHODS A retrospective cohort study was conducted using data from patients with acute iliofemoral DVT who received initial LMWH anticoagulation followed by rivaroxaban maintenance therapy. The clinical outcomes were compared between early (LMWH course ≤7 days) and routine (LMWH course >7 days) switching strategies within 3 months of initiating anticoagulation. RESULTS 217 patients were included, 59 (27.2%) receiving early switching and 158 (72.8%) receiving routine switching. Compared with routine switching, patients with early switching had a significantly shorter hospital stay (7 days vs. 14 days, P < 0.001). The length of hospital stay was significantly positively correlated with the duration of LMWH (r = 0.762, P < 0.001). The incidences of recurrent venous thromboembolism (5.1% vs. 2.5%, P = 0.606), major bleeding (0% vs. 1.9%, P = 0.564), clinically relevant nonmajor bleeding (1.7% vs. 2.5%, P = 1.000) and all-cause mortality (6.8% vs. 2.5%, P = 0.283) were not statistically different between the 2 groups. CONCLUSIONS Direct early switching from LMWH to maintenance therapy of rivaroxaban is effective and safe for acute iliofemoral DVT.
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Affiliation(s)
- Wei Hou
- Department of Pharmacy, Tianjin Hospital, Tianjin, China
| | - Demin Fang
- Department of Pharmacy, Tianjin Hospital, Tianjin, China
| | - Shugang Yin
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, China
| | - Yajing Deng
- Department of Pharmacy, Tianjin Hospital, Tianjin, China
| | - Jinhong Zhang
- Department of Pharmacy, Tianjin Hospital, Tianjin, China
| | - Siting Wang
- School of Public Health, Tianjin Medical University, Tianjin, China
| | - Liguo Liu
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, China
| | - Jingbo Kong
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, China
| | - Mei Huang
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, China
| | - Xiujun Zhang
- Department of Vascular Surgery, Tianjin Hospital, Tianjin, China
| | - Bin Dai
- Department of Pharmacy, Tianjin Hospital, Tianjin, China
| | - Xin Feng
- Department of Pharmacy, Tianjin Hospital, Tianjin, China.
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17
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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18
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Nishimura T, Hirata Y, Ise T, Iwano H, Izutani H, Kinugawa K, Kitai T, Ohno T, Ohtani T, Okumura T, Ono M, Satomi K, Shiose A, Toda K, Tsukamoto Y, Yamaguchi O, Fujino T, Hashimoto T, Higashi H, Higashino A, Kondo T, Kurobe H, Miyoshi T, Nakamoto K, Nakamura M, Saito T, Saku K, Shimada S, Sonoda H, Unai S, Ushijima T, Watanabe T, Yahagi K, Fukushima N, Inomata T, Kyo S, Minamino T, Minatoya K, Sakata Y, Sawa Y. JCS/JSCVS/JCC/CVIT 2023 Guideline Focused Update on Indication and Operation of PCPS/ECMO/IMPELLA. Circ J 2024; 88:1010-1046. [PMID: 38583962 DOI: 10.1253/circj.cj-23-0698] [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] [Indexed: 04/09/2024]
Affiliation(s)
- Takashi Nishimura
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Yasutaka Hirata
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Takayuki Ise
- Department of Cardiovascular Medicine, Tokushima University Hospital
| | | | - Hironori Izutani
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | | | - Takeshi Kitai
- Department of Heart Failure and Transplantation, National Cerebral and Cardiovascular Center
| | - Takayuki Ohno
- Division of Cardiovascular Surgery, Mitsui Memorial Hospital
| | - Tomohito Ohtani
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiovascular Surgery, Graduate School of Medicine, The University of Tokyo
| | - Kazuhiro Satomi
- Department of Cardiovascular Medicine, Tokyo Medical University Hospital
| | - Akira Shiose
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Koichi Toda
- Department of Thoracic and Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center
| | - Yasumasa Tsukamoto
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Takeo Fujino
- Department of Advanced Cardiopulmonary Failure, Faculty of Medical Sciences, Kyushu University
| | - Toru Hashimoto
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | | | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hirotsugu Kurobe
- Department of Cardiovascular and Thoracic Surgery, Ehime University Graduate School of Medicine
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine
| | - Kei Nakamoto
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | - Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
| | - Tetsuya Saito
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Keita Saku
- Department of Cardiovascular Dynamics, National Cerebral and Cardiovascular Center
| | - Shogo Shimada
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | - Hiromichi Sonoda
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Shinya Unai
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic
| | - Tomoki Ushijima
- Department of Cardiovascular Surgery, Kyushu University Hospital
| | - Takuya Watanabe
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center
| | | | | | - Takayuki Inomata
- Department of Cardiovascular Medicine, Niigata University Graduate School of Medical and Dental Sciences
| | - Shunei Kyo
- Tokyo Metropolitan Institute for Geriatrics and Gerontology
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
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19
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Mabuchi H, Nishikawa R, Yamashita Y, Morimoto T, Chatani R, Kaneda K, Nishimoto Y, Ikeda N, Kobayashi Y, Ikeda S, Kim K, Inoko M, Takase T, Tsuji S, Oi M, Takada T, Otsui K, Sakamoto J, Ogihara Y, Inoue T, Usami S, Chen PM, Togi K, Koitabashi N, Hiramori S, Doi K, Tsuyuki Y, Murata K, Takabayashi K, Nakai H, Sueta D, Shioyama W, Dohke T, Ono K, Nakagawa Y, Kimura T. Statins use and recurrent venous thromboembolism in the direct oral anticoagulant era: insight from the COMMAND VTE Registry-2. J Thromb Thrombolysis 2024:10.1007/s11239-024-03002-0. [PMID: 38762713 DOI: 10.1007/s11239-024-03002-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
Statins were reported to have a potential effect of primary prevention of venous thromboembolism (VTE), although that of secondary prevention remains uncertain. To investigate the association between statins use and recurrent VTE in the current era. The COMMAND VTE Registry-2 is a multicenter registry enrolling 5,197 consecutive VTE patients among 31 centers in Japan between January 2015 and August 2020. We divided the entire cohort into 2 groups according to statins use at the time of discharge; the statins (N = 865) and no statins groups (N = 4332). The statins group was older (72.9 vs. 66.7 years, P < 0.001), and less often had active cancer (22.0% vs. 30.4%, P < 0.001). The cumulative incidence of discontinuation of anticoagulation was significantly lower in the statins group (60.3% vs. 52.6%, Log-rank P < 0.001). The cumulative 5-year incidence of recurrent VTE was significantly lower in the statins group (6.8% vs. 10.1%, Log-rank P = 0.01). Even after adjusting for the confounders, the lower risk of the statins group relative to the no statins group remained significant for recurrent VTE (HR 0.65, 95% CI 0.45-0.91, P = 0.01). The cumulative 5-year incidence of major bleeding was significantly lower in the statins group (12.2% vs. 14.1%, Log-rank P = 0.04), although, after adjusting for the confounders, the risk of the statins group relative to the no statins group turned to be insignificant (HR 0.77, 95% CI 0.59-1.00, P = 0.054). In this large real-world VTE registry, statins use was significantly associated with a lower risk for the recurrent VTE in the current era.
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Affiliation(s)
- Hiroshi Mabuchi
- Department of Cardiology, Koto Memorial Hospital, Higashiomi, Japan
| | - Ryusuke Nishikawa
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yugo Yamashita
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Ryuki Chatani
- Department of Cardiovascular Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kazuhisa Kaneda
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yuji Nishimoto
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Nobutaka Ikeda
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yohei Kobayashi
- Department of Cardiovascular Center, Osaka Red Cross Hospital, Osaka, Japan
| | - Satoshi Ikeda
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Kitae Kim
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Moriaki Inoko
- Cardiovascular Center, The Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan
| | - Toru Takase
- Department of Cardiology, Kinki University Hospital, Osaka, Japan
| | - Shuhei Tsuji
- Department of Cardiology, Japanese Red Cross Wakayama Medical Center, Wakayama, Japan
| | - Maki Oi
- Department of Cardiology, Japanese Red Cross Otsu Hospital, Otsu, Japan
| | - Takuma Takada
- Department of Cardiology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazunori Otsui
- Department of General Internal Medicine, Kobe University Hospital, Kobe, Japan
| | - Jiro Sakamoto
- Department of Cardiology, Tenri Hospital, Tenri, Japan
| | - Yoshito Ogihara
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Inoue
- Department of Cardiology, Shiga General Hospital, Moriyama, Japan
| | - Shunsuke Usami
- Department of Cardiology, Kansai Electric Power Hospital, Osaka, Japan
| | - Po-Min Chen
- Department of Cardiology, Osaka Saiseikai Noe Hospital, Osaka, Japan
| | - Kiyonori Togi
- Division of Cardiology, Nara Hospital, Kinki University Faculty of Medicine, Ikoma, Japan
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Seiichi Hiramori
- Department of Cardiology, Kokura Memorial Hospital, Kokura, Japan
| | - Kosuke Doi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Yoshiaki Tsuyuki
- Division of Cardiology, Shimada General Medical Center, Shimada, Japan
| | - Koichiro Murata
- Department of Cardiology, Shizuoka City Shizuoka Hospital, Shizuoka, Japan
| | | | - Hisato Nakai
- Department of Cardiovascular Medicine, Sugita Genpaku Memorial Obama Municipal Hospital, Obama, Japan
| | - Daisuke Sueta
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Wataru Shioyama
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Tomohiro Dohke
- Division of Cardiology, Kohka Public Hospital, Koka, Japan
| | - Koh Ono
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Yoshihisa Nakagawa
- Department of Cardiovascular Medicine, Shiga University of Medical Science, Otsu, Japan
| | - Takeshi Kimura
- Department of Cardiology, Hirakata Kohsai Hospital, Hirakata, Japan
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20
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Zuin M, Henkin S, Harder EM, Piazza G. Optimal hemodynamic parameters for risk stratification in acute pulmonary embolism patients. J Thromb Thrombolysis 2024:10.1007/s11239-024-02998-9. [PMID: 38762710 DOI: 10.1007/s11239-024-02998-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 05/20/2024]
Abstract
Hemodynamic assessment of patients with pulmonary embolism (PE) remains a fundamental component of early risk stratification that in turn, influences subsequent monitoring and therapeutic strategies. The current body of literature and international evidence-based clinical practice guidelines focus mainly on the use of systolic blood pressure (SBP). The accuracy of this single hemodynamic parameter, however, and its optimal values for the identification of hemodynamic instability have been recently questioned by clinicians. For example, abnormal SBP or shock index may be a late indicator of adverse outcomes, signaling a patient in whom the cascade of hemodynamic compromise is already well underway. The aim of the present article is to review the current evidence supporting the use of SBP and analyze the potential integration of other parameters to assess the hemodynamic stability, impending clinical deterioration, and guide the reperfusion treatment in patients with PE, as well as to suggest potential strategies to further investigate this issue.
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Affiliation(s)
- Marco Zuin
- Department of Translational Medicine, University of Ferrara, Via Aldo Moro 8, Ferrara, 44124, Italy.
| | | | - Eileen M Harder
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory Piazza
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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21
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Fontyn S, Bai Y, Bolger S, Greco K, Wang TF, Hamm C, Cervi A. Inferior vena cava filter use at a large community hospital: a retrospective cohort study. Sci Rep 2024; 14:10192. [PMID: 38702341 PMCID: PMC11068867 DOI: 10.1038/s41598-024-60868-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
Inferior vena cava (IVC) filters are considered when patients with venous thromboembolism (VTE) develop a contraindication to anticoagulation. Use of IVC filters is increasing, despite associated complications and lack of data on efficacy in reducing VTE-related mortality. We characterized the pattern of IVC filter use at a large community hospital between 2018 and 2022. Specifically, we assessed the indications for IVC filter insertion, filter removal rates, and filter-associated complications. Indications for IVC filters were compared to those outlined by current clinical practice guidelines. We reviewed 120 consecutive filter placement events. The most common indications included recent VTE and active bleeding (40.0%) or need for anticoagulation interruption for surgery (25.8%). Approximately one-third (30.0%) of IVC filters were inserted for indications either not supported or addressed by guidelines. Half (50.0%) of patients had successful removal of their IVC filter. At least 13 patients (10.8%) experienced a filter-related complication. In a large community-based practice, nearly one-third of IVC filters were inserted for indications not universally supported by current practice guidelines. Moreover, most IVC filters were not removed, raising the risk of filter-associated complications, and supporting the need for development of comprehensive guidelines addressing use of IVC filters, and post-insertion monitoring practices.
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Affiliation(s)
| | - Yuxin Bai
- Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Samantha Bolger
- Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Kaity Greco
- Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Caroline Hamm
- Schulich School of Medicine and Dentistry, London, ON, Canada
- Department of Medical Oncology, Windsor Regional Cancer Centre, 1995 Lens Avenue, Windsor, ON, N8W 1L9, Canada
| | - Andrea Cervi
- Schulich School of Medicine and Dentistry, London, ON, Canada.
- Department of Medical Oncology, Windsor Regional Cancer Centre, 1995 Lens Avenue, Windsor, ON, N8W 1L9, Canada.
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22
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Hampton Gray W, Sorabella RA, Law M, Padilla LA, Byrnes JW, Dabal RJ, Clark MG. Hybrid Thrombectomy and Central Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism in a Child. World J Pediatr Congenit Heart Surg 2024; 15:394-396. [PMID: 38263666 DOI: 10.1177/21501351231221430] [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: 01/25/2024]
Abstract
We describe a hybrid thrombectomy and central extracorporeal membrane oxygenation for a child in cardiogenic shock due to a massive pulmonary embolism.
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Affiliation(s)
- W Hampton Gray
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert A Sorabella
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Law
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Luz A Padilla
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jonathan W Byrnes
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert J Dabal
- Division of Cardiothoracic Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew G Clark
- Division of Pediatric Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, USA
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23
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Cardona S, Downing JV, Witting MD, Haase DJ, Powell EK, Dahi S, Pasrija C, Tran QK. Venoarterial Extracorporeal Membrane Oxygenation With or Without Advanced Intervention for Massive Pulmonary Embolism. Perfusion 2024; 39:665-674. [PMID: 37246150 DOI: 10.1177/02676591231177909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study's objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010-2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests. RESULTS We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9-3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications. CONCLUSION Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Jessica V Downing
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth K Powell
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Quincy K Tran
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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24
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Madonna R, Alberti M, Biondi F, Morganti R, Badagliacca R, Vizza CD, De Caterina R. Chronic thromboembolic pulmonary disease: Association with exercise-induced pulmonary hypertension and right ventricle adaptation over time. Eur J Intern Med 2024; 123:120-126. [PMID: 38042668 DOI: 10.1016/j.ejim.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 11/12/2023] [Accepted: 11/20/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND AND AIM Chronic thromboembolic pulmonary disease (CTEPD) is a progressive condition caused by fibrotic thrombi and vascular remodeling in the pulmonary circulation despite prolonged anticoagulation. We evaluated clinical factors associated with CTEPD, as well as its impact on functional capacity, pulmonary haemodynamics at rest and after exercise, and right ventricle (RV) morphology and function. METHODS We compared 33 consecutive patients with a history of acute pulmonary embolism and either normal pulmonary vascular imaging (negative Q-scan, group 1, n = 16) or persistent defects on lung perfusion scan (positive Q-scan) despite oral anticoagulation at 4 months (group 2, n = 17). Investigations included thrombotic load, the Pulmonary Embolism Severity Index (PESI) score, functional class, N-terminal prohormone of brain natriuretic peptide (NT-proBNP), cardiopulmonary exercise test (CPET) and echocardiographic parameters at rest and after exercise (ESE), at 4 and at 24 months. RESULTS Compared with group 1, group 2 featured a higher PESI score (p = 0.02) and a higher thrombotic load (p = 0.004) at hospital admission. At 4 months, group 2 developed exercise-induced pulmonary hypertension (Ex-PH) at CPET (p < 0.001) and ESE (p < 0.001). At 24 months group 2 showed higher NT-proBNP (p < 0.001), WHO-FC (p < 0.001), systolic (p<0.001) and diastolic (p = 0.037) RV dysfunction and worse RV-arterial coupling (p < 0.001) despite maintaining a low or intermediate echocardiographic probability of PH. CONCLUSIONS This is the first "proof of concept" study showing that patients with a positive Q-scan frequently develop Ex-PH and RV functional deterioration as well as reduced functional capacity, generating the hypothesis that Ex-PH could help detect the progression to CTEPD.
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Affiliation(s)
- Rosalinda Madonna
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy
| | - Mattia Alberti
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy
| | - Filippo Biondi
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy
| | | | - Roberto Badagliacca
- Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University, of Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Anesthesiologic and Cardiovascular Sciences, Sapienza University, of Rome, Italy
| | - Raffaele De Caterina
- University Cardiology Division, Pisa University Hospital and University of Pisa, Via Paradisa, 2, Pisa 56124, Italy.
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Birrenkott DA, Kabrhel C, Dudzinski DM. Intermediate-Risk and High-Risk Pulmonary Embolism: Recognition and Management: Cardiology Clinics: Cardiac Emergencies. Cardiol Clin 2024; 42:215-235. [PMID: 38631791 DOI: 10.1016/j.ccl.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Pulmonary embolism (PE) is the third most common cause of cardiovascular death. Every specialty of medical practitioner will encounter PE in their patients, and should be prepared to employ contemporary strategies for diagnosis and initial risk-stratification. Treatment of PE is based on risk-stratification, with anticoagulation for all patients, and advanced modalities including systemic thrombolysis, catheter-directed therapies, and mechanical circulatory supports utilized in a manner paralleling PE severity and clinical context.
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Affiliation(s)
- Drew A Birrenkott
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Center for Vascular Emergencies, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Division of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; Cardiac Intensive Care Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA.
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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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27
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Rouleau SG, Casey SD, Kabrhel C, Vinson DR, Long B. Management of high-risk pulmonary embolism in the emergency department: A narrative review. Am J Emerg Med 2024; 79:1-11. [PMID: 38330877 DOI: 10.1016/j.ajem.2024.01.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 12/22/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND High-risk pulmonary embolism (PE) is a complex, life-threatening condition, and emergency clinicians must be ready to resuscitate and rapidly pursue primary reperfusion therapy. The first-line reperfusion therapy for patients with high-risk PE is systemic thrombolytics (ST). Despite consensus guidelines, only a fraction of eligible patients receive ST for high-risk PE. OBJECTIVE This review provides emergency clinicians with a comprehensive overview of the current evidence regarding the management of high-risk PE with an emphasis on ST and other reperfusion therapies to address the gap between practice and guideline recommendations. DISCUSSION High-risk PE is defined as PE that causes hemodynamic instability. The high mortality rate and dynamic pathophysiology of high-risk PE make it challenging to manage. Initial stabilization of the decompensating patient includes vasopressor administration and supplemental oxygen or high-flow nasal cannula. Primary reperfusion therapy should be pursued for those with high-risk PE, and consensus guidelines recommend the use of ST for high-risk PE based on studies demonstrating benefit. Other options for reperfusion include surgical embolectomy and catheter directed interventions. CONCLUSIONS Emergency clinicians must possess an understanding of high-risk PE including the clinical assessment, pathophysiology, management of hemodynamic instability and respiratory failure, and primary reperfusion therapies.
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Affiliation(s)
- Samuel G Rouleau
- Department of Emergency Medicine, UC Davis Health, University of California, Davis, Sacramento, CA, United States of America.
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, CA, United States of America.
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America.
| | - David R Vinson
- Kaiser Permanente Northern California Division of Research, The Permanente Medical Group, Oakland, CA, United States of America; Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, CA, United States of America.
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, United States of America.
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Gardner TA, Fuher A, Longino A, Sink EM, Jurica J, Park B, Lindquist J, Bull TM, Hountras P. Reduced mortality associated with pulmonary embolism response team consultation for intermediate and high-risk pulmonary embolism: a retrospective cohort study. Thromb J 2024; 22:38. [PMID: 38641802 PMCID: PMC11027408 DOI: 10.1186/s12959-024-00605-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 04/05/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND The management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation. METHODS At a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation. RESULTS Six hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS. (-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011). These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras. CONCLUSIONS We observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.
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Affiliation(s)
- Tiffany A Gardner
- Pulmonary and Critical Care Fellowship Program, Massachusetts General Hospital & Beth Israel Deaconess Medical Center, Boston, MA, 02114, USA.
| | - Alexandra Fuher
- Internal Medicine Residency Program, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - August Longino
- Internal Medicine Residency Program, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Eric M Sink
- Internal Medicine Residency Program, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - James Jurica
- Internal Medicine Residency Program, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Bryan Park
- Division of Pulmonary Sciences & Critical Care, Pulmonary Vascular Disease Center, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jonathan Lindquist
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Todd M Bull
- Division of Pulmonary Sciences & Critical Care, Pulmonary Vascular Disease Center, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Peter Hountras
- Division of Pulmonary Sciences & Critical Care, Pulmonary Vascular Disease Center, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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29
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Donadini MP, Mumoli N, Fenu P, Pomero F, Re R, Palmiero G, Spadafora L, Mazzi V, Grittini A, Bertù L, Aujesky D, Dentali F, Ageno W, Squizzato A. The Clinical Impact of the Pulmonary Embolism Severity Index on the Length of Hospital Stay of Patients with Pulmonary Embolism: A Randomized Controlled Trial. Diagnostics (Basel) 2024; 14:776. [PMID: 38611689 PMCID: PMC11011567 DOI: 10.3390/diagnostics14070776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 04/02/2024] [Accepted: 04/04/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND The Pulmonary Embolism Severity Index (PESI) is an extensively validated prognostic score, but impact analyses of the PESI on management strategies, outcomes and health care costs are lacking. Our aim was to assess whether the adoption of the PESI for patients admitted to an internal medicine ward has the potential to safely reduce the length of hospital stay (LOS). METHODS We carried out a multicenter randomized controlled trial, enrolling consecutive adult outpatients diagnosed with acute PE and admitted to an internal medicine ward. Within 48 h after diagnosis, the treating physicians were randomized, for every patient, to calculate and report the PESI in the clinical record form on top of the standard of care (experimental arm) or to continue routine clinical practice (standard of care). The ClinicalTrials.gov identifier is NCT03002467. RESULTS This study was prematurely stopped due to slow recruitment. A total of 118 patients were enrolled at six internal medicine units from 2016 to 2019. The treating physicians were randomized to the use of the PESI for 59 patients or to the standard of care for 59 patients. No difference in the median LOS was found between the experimental arm (8, IQR 6-12) and the standard-of-care arm (8, IQR 6-12) (p = 0.63). A pre-specified secondary analysis showed that the LOS was significantly shorter among the patients who were treated with DOACs (median of 8 days, IQR 5-11) compared to VKAs or heparin (median of 9 days, IQR 7-12) (p = 0.04). CONCLUSIONS The formal calculation of the PESI in the patients already admitted to internal medicine units did not impact the length of hospital stay.
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Affiliation(s)
- Marco Paolo Donadini
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Nicola Mumoli
- Department of Internal Medicine, Magenta Hospital, 20013 Magenta, Italy;
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | - Patrizia Fenu
- Presidio Ospedaliero di Cecina, Azienda USL Toscana Nord Ovest, 57023 Cecina, Italy;
| | - Fulvio Pomero
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Roberta Re
- Medicina Interna, Ospedale S. Andrea, ASL Vercelli, 13100 Vercelli, Italy;
| | - Gerardo Palmiero
- Ospedale Versilia, Azienda USL Toscana Nord Ovest, 55049 Viareggio, Italy;
| | - Laura Spadafora
- Internal Medicine Unit, Michele e Pietro Ferrero Hospital, 12060 Verduno, Italy; (F.P.); (L.S.)
| | - Valeria Mazzi
- Presidio Ospedaliero di Livorno, Azienda USL Toscana Nord Ovest, 57124 Livorno, Italy;
| | | | - Lorenza Bertù
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Drahomir Aujesky
- Department of General Internal Medicine, Bern University Hospital, University of Bern, 3010 Bern, Switzerland;
| | - Francesco Dentali
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Walter Ageno
- Thrombosis and Haemostasis Center, Ospedale di Circolo, ASST Sette Laghi, 21100 Varese, Italy; (M.P.D.); (F.D.); (W.A.)
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
| | - Alessandro Squizzato
- Research Center on Thromboembolic Diseases and Antithrombotic Therapies, University of Insubria, 21100 Varese and 22100 Como, Italy; (L.B.); (A.S.)
- Internal Medicine Unit, ‘Sant’Anna’ Hospital, ASST Lariana, 22042 San Fermo della Battagli, Italy
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López N, Zamora-Martinez C, Montoya-Rodes M, Gabara C, Ortiz M, Aibar J. Comparison of inferior vena cava filter use and outcomes between cancer and non-cancer patients in a tertiary hospital. Thromb Res 2024; 236:136-143. [PMID: 38447420 DOI: 10.1016/j.thromres.2024.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Abstract
BACKGROUND While accepted indications for the use of inferior vena cava filter (IVCF) in patients with a venous thromboembolism (VTE) have remained stable, their use continues to be frequent. Retrieval rates are still low, being particularly notable in the population with cancer. This study aims to review the rate of adherence to guidelines recommendation and to compare retrieval rates and complications in both cancer and non-cancer patients. METHODS A retrospective study was performed including 185 patients in whom an IVCF was placed in Hospital Clinic of Barcelona. Baseline characteristics, clinical outcomes, and IVCF-related outcomes were analyzed. A strongly recommended indication (SRI) was considered if it was included in all the revised clinical guidelines and non-strongly if it was included in only some. RESULTS Overall, 47 % of the patients had a SRI, without differences between groups. IVCF placement after 29 days from the VTE event was more frequent in the cancer group (46.1 vs. 17.7 %). Patients with cancer (48.1 % of the cohort) were older, with higher co-morbidity and bleeding risk. Anticoagulation resumption (75.3 % vs. 92.7 %) and IVCF retrieval (50.6 % vs. 66.7 %) were significantly less frequent in cancer patients. No significant differences were found regarding IVCF-related complications, hemorrhagic events and VTE recurrence. CONCLUSIONS SRI of IVCF placement was found in less than half of the patients. Cancer patients had higher rates of IVCF placement without indication and lower anticoagulation resumption and IVCF retrieval ratios, despite complications were similar in both groups.
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Affiliation(s)
- Néstor López
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Carles Zamora-Martinez
- Medical Oncology Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain.
| | - Marc Montoya-Rodes
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Cristina Gabara
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - María Ortiz
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jesús Aibar
- Internal Medicine Department, Hospital Clinic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
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Rastogi R, Okunowo O, Faerber JA, Mavroudis CD, Whitworth H, Giglia TM, Witmer C, Raffini LJ, O'Byrne ML. Incidence, Management, and Outcomes of Pulmonary Embolism at Tertiary Pediatric Hospitals in the United States. JACC. ADVANCES 2024; 3:100895. [PMID: 38939674 PMCID: PMC11198360 DOI: 10.1016/j.jacadv.2024.100895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 12/18/2023] [Accepted: 01/02/2024] [Indexed: 06/29/2024]
Abstract
Background Pediatric pulmonary embolism (PE) is rare and potentially life-threatening. Though thrombolysis and thrombectomy are increasingly used in adult PE, trends in pediatric treatment and outcomes remain incompletely described. Objectives The purpose of this study was to describe the incidence of PE, proportion of cases treated with anticoagulation alone, systemic thrombolysis, and directed therapy (local thrombolysis and thrombectomy), clinical outcomes, and total costs. Methods A multicenter observational study was performed using administrative data from the Pediatric Health Information System database to study PE treated at U.S. pediatric hospitals from 2015 to 2021. Outcomes by treatment were evaluated using multivariable generalized linear mixed effects models. Results Of 3,136 subjects, 70% were at least 12 years of age, and 46% were male. Sixty-two percent had at least 1 comorbidity, and congenital heart disease of any kind was the most prevalent (20%). Eighty-eight percent of subjects received anticoagulation alone, 7% received systemic thrombolysis, and 5% received directed therapy. Overall in-hospital mortality was 7.5%. Treatment approach did not change over time (P = 0.98). After adjusting for patient characteristics, directed therapy was associated with a lower risk of mortality (adjusted percentage -3%, [95% CI: -5% to 0%]) than anticoagulation alone. Systemic thrombolysis was associated with a greater total cost of hospitalization ($113,043 greater [95% CI: $62,866, $163,219]). Length of hospital stay did not differ by treatment. Conclusions Pediatric patients with PE have a high incidence of underlying chronic disease. Anticoagulation alone remains the mainstay of treatment, with thrombolysis and thrombectomy rarely being used. Given the relative rarity of pediatric PE, additional research requiring innovative study designs is paramount.
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Affiliation(s)
- Radhika Rastogi
- Department of Pediatrics, The Children’s Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oluwatimilehin Okunowo
- Division of Biostatistics, Department of Computational and Quantitative Medicine, Beckman Research Institute of City of Hope, Duarte, California, USA
| | - Jennifer A. Faerber
- Data Science and Biostatistics Unit, Department of Biomedical and Health Informatics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Constantine D. Mavroudis
- Division of Cardiothoracic Surgery, Department of Surgery, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hilary Whitworth
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese M. Giglia
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Char Witmer
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leslie J. Raffini
- Division of Hematology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael L. O'Byrne
- Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Wilson R, Eguchi S, Orihara Y, Pfeiffer M, Peterson B, Ruzieh M, Gao Z, Gorcsan J, Boehmer J. Association between right ventricular global longitudinal strain and mortality in intermediate-risk pulmonary embolism. Echocardiography 2024; 41:e15815. [PMID: 38634182 DOI: 10.1111/echo.15815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/31/2024] [Accepted: 04/01/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Right ventricular (RV) systolic dysfunction has been identified as a prognostic marker for adverse clinical events in patients presenting with acute pulmonary embolism (PE). However, challenges exist in identifying RV dysfunction using conventional echocardiography techniques. Strain echocardiography is an evolving imaging modality which measures myocardial deformation and can be used as an objective index of RV systolic function. This study evaluated RV Global Longitudinal Strain (RVGLS) in patients with intermediate risk PE as a parameter of RV dysfunction, and compared to traditional echocardiographic and CT parameters evaluating short-term mortality. METHODS Retrospective single center cohort study of 251 patients with intermediate-risk PE between 2010 and 2018. The primary outcome was all-cause mortality at 30 days. Statistical analysis evaluated each parameter comparing survivors versus non-survivors at 30 days. Receiver operating characteristic (ROC) curves and Kaplan-Meier curves were used for comparison of the two cohorts. RESULTS Altogether 251 patients were evaluated. Overall mortality rate was 12.4%. Utilizing an ROC curve, an absolute cutoff value of 17.7 for RVGLS demonstrated a sensitivity of 93% and specificity of 70% for observed 30-day mortality. Individuals with an RVGLS ≤17.7 had a 25 times higher mortality rate than those with RVGLS above 17.7 (HR 25.24, 95% CI = 6.0-106.4, p < .001). Area under the curve was (.855), RVGLS outperformed traditional echocardiographic parameters, CT findings, and cardiac biomarkers on univariable and multivariable analysis. CONCLUSIONS Reduced RVGLS values on initial echocardiographic assessment of patients with intermediate-risk PE identified patients at higher risk for mortality at 30 days.
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Affiliation(s)
- Ryan Wilson
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Shunsuke Eguchi
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Yoshiyuki Orihara
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Michael Pfeiffer
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Brandon Peterson
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - Mohammed Ruzieh
- Division of Cardiovascular Medicine, College of Medicine, University of Florida, Gainsville, Florida, USA
| | - Zhaohui Gao
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - John Gorcsan
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
| | - John Boehmer
- Division of Cardiology, Heart and Vascular Institute, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania, USA
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Chijik A, Jerdev M, Dahoud WA, Sela Y, Blum A. RV size may predict death in unstable patients with PE. Ir J Med Sci 2024; 193:671-675. [PMID: 37639161 DOI: 10.1007/s11845-023-03508-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Pulmonary emboli (PE) is a life threatening condition that discovered in many patients only "post mortem". Sub massive and massive PE that led to hemodynamic collapse characterized by right ventricular (RV) dysfunction, leading to a higher risk of death. OBJECTIVES To assess the ability to predict in hospital death of patients with acute PE, using a non-gated computed tomography pulmonary angiography (CTPA), based on the dimensions of the right ventricle. METHODS A retrospective study that analyzed CTPA images of patients admitted with acute PE during the years 2012-2017. The cohort study included 300 patients with documented acute PE, among them 255 hospitalized in medical (non-intensive care unit) wards, 45 were hospitalized in an intensive care unit (ICU). RESULTS Among the 45 patients admitted to the ICU 8% died. Larger RV diameters predicted mortality (OR = 10.14, 95% CI [1.09-93.86]) as well as lower systolic and diastolic blood pressure measurements (p = 0.001 and 0.01). Among the 255 patients admitted to the Internal Medicine Ward 7% died. Older age (p = 0.028), sepsis and cancer (both p < 0.001), high WBCs count (p < 0.001), and renal failure (p < 0.001) predicted death. Lower blood pressure (systolic and diastolic) (p < 0.001, 0.008), older age (p < 0.007), sepsis (p < 0.001), cancer (p = 0.006), higher WBCs count (p < 0.001), and impaired renal function (p < 0.001) predicted death in patients admitted with acute PE. CONCLUSIONS Clinical parameters and hematological parameters could predict death of patients admitted with acute PE. RV diameter, measured by the non-ECG gated CTPA, had an additive predictive value for patients who admitted to the ICU.
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Affiliation(s)
| | - Michael Jerdev
- Imaging Department, Tzafon Medical Center, Tiberias, Israel
| | | | - Yaron Sela
- Epidemiology and Statistics, Reichman University, Herzlia, Israel
| | - Arnon Blum
- Department of Medicine, Laniado Hospital, Netanya, Adelson School of Medicine, Ariel University, Ariel, Israel.
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Lei J, Pu H, Zhang L, Zeng C, Peng Z, Wu Z, Jiang Y, Wang R, Lu X. Drug-coated balloon therapy for in-stent restenosis in patients with iliofemoral deep vein thrombosis: A single-arm observational study. Catheter Cardiovasc Interv 2024; 103:752-757. [PMID: 38385905 DOI: 10.1002/ccd.30975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/13/2023] [Accepted: 02/02/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Iliofemoral deep vein thrombosis (IFDVT) causes severe symptoms and affect the quality of life to a great extent. Endovascular thrombectomy and stent implantation have been a feasible strategie to alleviate the signs and symptoms of IFDVT. However, venous in-stent restenosis (ISR) has become an emerging non-negligible problem. METHODS To evaluate the histological characteristics of venous ISR, neointima of arterial and venous ISR patients were collected and examed. To explore the effect of drug-coated balloon (DCB) on venous ISR lesions, we conducted a single-center retrospective case series study involving IFDVT patients with ISR after venous stenting who were treated with paclitaxel-coated balloon dilatation. RESULTS We found a collagen-rich matrix but not elastin, as well as fewer cells and less neovascularization in venous intimal hyperplasia compared with neointima in arteries. Thirteen IFDVT patients were involved in the study, with average preoperative stenosis degree of 87.69% ± 13.48%. After intervention, the stenosis degree was significantly reduced to 14.6% ± 14.36% immediately (p < 0.0001) and to 16.54% ± 15.73% during follow-up (p < 0.0001). During follow-up, the VEINES-QOL scores (p < 0.0001), VEINES-Sym scores (p < 0.0001), and Villalta scores (p = 0.04) of patients was improved significantly compared with those before intervention. No major adverse events were observed. CONCLUSIONS The use of DCB may have a positive effect in the treatment of venous ISR by targeting intimal hyperplasia. Moreover, the application of DCB dilatation in IFDVT stenting patients with ISR is deemed safe and effective.
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Affiliation(s)
- Jiahao Lei
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Hongji Pu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Linjie Zhang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Chenlin Zeng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhaoxi Peng
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Zhaoyu Wu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Yihong Jiang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
| | - Ruihua Wang
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, People's Republic of China
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, People's Republic of China
- Shanghai Key Laboratory of Tissue Engineering, Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, People's Republic of China
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Khandait H, Hanif M, Ramadan A, Attia AM, Endurance E, Siddiq A, Iqbal U, Song D, Chaudhuri D. A meta-analysis of outcomes of aspiration thrombectomy for high and intermediate-risk pulmonary embolism. Curr Probl Cardiol 2024; 49:102420. [PMID: 38290623 DOI: 10.1016/j.cpcardiol.2024.102420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 01/18/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND Aspiration thrombectomy has gained popularity in patients with massive and sub-massive pulmonary embolism (PE) and having contraindications to thrombolysis. METHODS A meta-analysis was conducted including studies on aspiration thrombectomy in patients with high-risk and intermediate-risk PE. The pooled odds ratio for efficacy parameters, including change in heart rate, blood pressure and right ventricle/left ventricle (RV/LV) ratio, and safety parameters including major bleeding and stroke, was calculated using a random effects model. RESULTS The meta-analysis of 24 selected studies revealed that intermediate and high-risk pulmonary embolism (PE) patients demonstrated significant improvements: modified Miller score odds ratio of 10.60, mean pulmonary artery pressure reduction by 0.04 mm Hg, and an overall all-cause mortality odds ratio of 0.10. Considerable heterogeneity was observed in various outcomes. CONCLUSION Aspiration thrombectomy has success rates in both high-risk and intermediate-risk PE, however, procedural risks, including bleeding, must be anticipated.
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Affiliation(s)
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Alaa Ramadan
- Faculty of Medicine, South Valley University, Qena, Egypt
| | | | | | | | - Unzela Iqbal
- Trinitas Regional Medical Center/RWJ Barnabas Health, NJ, USA
| | - David Song
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai Elmhurst Hospital Center, Queens NY, USA
| | - Debanik Chaudhuri
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
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Falsetti L, Guerrieri E, Zaccone V, Viticchi G, Santini S, Giovenali L, Lagonigro G, Carletti S, Gialluca Palma LE, Tarquinio N, Moroncini G. Cutting-Edge Techniques and Drugs for the Treatment of Pulmonary Embolism: Current Knowledge and Future Perspectives. J Clin Med 2024; 13:1952. [PMID: 38610717 PMCID: PMC11012374 DOI: 10.3390/jcm13071952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/11/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Pulmonary embolism (PE) is a potentially life-threatening condition requiring prompt diagnosis and treatment. Recent advances have led to the development of newer techniques and drugs aimed at improving PE management, reducing its associated morbidity and mortality and the complications related to anticoagulation. This review provides an overview of the current knowledge and future perspectives on PE treatment. Anticoagulation represents the first-line treatment of hemodynamically stable PE, direct oral anticoagulants being a safe and effective alternative to traditional anticoagulation: these drugs have a rapid onset of action, predictable pharmacokinetics, and low bleeding risk. Systemic fibrinolysis is suggested in patients with cardiac arrest, refractory hypotension, or shock due to PE. With this narrative review, we aim to assess the state of the art of newer techniques and drugs that could radically improve PE management in the near future: (i) mechanical thrombectomy and pulmonary embolectomy are promising techniques reserved to patients with massive PE and contraindications or failure to systemic thrombolysis; (ii) catheter-directed thrombolysis is a minimally invasive approach that can be suggested for the treatment of massive or submassive PE, but the lack of large, randomized controlled trials represents a limitation to widespread use; (iii) novel pharmacological approaches, by agents inhibiting thrombin-activatable fibrinolysis inhibitor, factor Xia, and the complement cascade, are currently under investigation to improve PE-related outcomes in specific settings.
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Affiliation(s)
- Lorenzo Falsetti
- Clinica Medica, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.F.)
| | - Emanuele Guerrieri
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Vincenzo Zaccone
- Internal and Subintensive Medicine, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
| | - Giovanna Viticchi
- Clinica di Neurologia, Dipartimento Scienze Cliniche e Molecolare, Università Politecnica delle Marche, 60126 Ancona, Italy
| | - Silvia Santini
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Laura Giovenali
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Graziana Lagonigro
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | - Stella Carletti
- Emergency Medicine Residency Program, Università Politecnica delle Marche, 60126 Ancona, Italy; (E.G.)
| | | | - Nicola Tarquinio
- Internal Medicine Department, INRCA-IRCCS Osimo-Ancona, 60027 Ancona, Italy
| | - Gianluca Moroncini
- Clinica Medica, Dipartimento di Scienze Cliniche e Molecolari, Università Politecnica delle Marche, 60126 Ancona, Italy; (L.F.)
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Li W, Lin Y, Su K, Cai F, Zhang J, Lai X, Zheng X, Guo P, Hou X, Dai Y. Syringe-assisted test-aspiration with mechanical aspiration thrombectomy results in good safety and short-term outcomes in the treatment of patients with deep venous thrombosis. Vascular 2024:17085381241242164. [PMID: 38531094 DOI: 10.1177/17085381241242164] [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: 03/28/2024]
Abstract
OBJECTIVE To evaluate the short-term outcomes and safety of syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis. METHODS This was a single-center, retrospective study of hospitalized patients with iliofemoral and/or inferior vena caval deep venous thrombosis, excluding those with pulmonary embolism. We collected the following patient data from the electronic medical records: age, sex, provoked/unprovoked deep venous thrombosis, symptom duration, thrombosed segments, and the presence of a tumor, thrombophilia, diabetes, and/or iliac vein compression syndrome. Venography and computed tomographic venography were performed in all patients before the procedure. All patients underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy under local anesthesia and sedation, and all received low-molecular-weight heparin peri-operatively. All patients underwent implantation of an inferior vena caval filter. Rivaroxaban was administered post-procedure, instead of heparin, for 3-6 months, with lower extremity compression. RESULTS Overall, 29 patients with deep venous thrombosis underwent syringe-assisted test-aspiration with mechanical aspiration thrombectomy from January 2022 to October 2022 in our institution. Technical success (>70% thrombus resolution) was achieved in all patients, and using a single procedure in 25/29 patients (86%). Concomitant stenting was performed in 18/29 (62%) of the patients, and 21/29 (69%) underwent angioplasty. The median (interquartile range) procedure time was 110 min (100-122), the median intra-operative bleeding volume was 150 mL (120-180), and the median decrease in the hemoglobin concentration from pre- to post-operative was 7 g/L (4-14). The median follow-up duration was 7 months (5-9). All patients obtained symptomatic relief, and 27/29 achieved near-remission or full remission (combined total). No patients experienced peri-operative bleeding complications, or symptom recurrence or post-thrombectomy syndrome during follow-up. CONCLUSION The short-term outcomes following syringe-assisted test-aspiration with mechanical aspiration thrombectomy in the treatment of deep venous thrombosis were excellent, and the procedure was safe.
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Affiliation(s)
- Wanglong Li
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yichen Lin
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Kunfeng Su
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Fujian, China
| | - Fanggang Cai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jinchi Zhang
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoling Lai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xiaoqi Zheng
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pingfan Guo
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Xinhuang Hou
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yiquan Dai
- Department of Vascular Surgery, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
- Department of Vascular Surgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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Wei C, Wang J, Yu P, Li A, Xiong Z, Yuan Z, Yu L, Luo J. Comparison of different machine learning classification models for predicting deep vein thrombosis in lower extremity fractures. Sci Rep 2024; 14:6901. [PMID: 38519523 PMCID: PMC10960026 DOI: 10.1038/s41598-024-57711-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 03/21/2024] [Indexed: 03/25/2024] Open
Abstract
Deep vein thrombosis (DVT) is a common complication in patients with lower extremity fractures. Once it occurs, it will seriously affect the quality of life and postoperative recovery of patients. Therefore, early prediction and prevention of DVT can effectively improve the prognosis of patients. This study constructed different machine learning models to explore their effectiveness in predicting DVT. Five prediction models were applied to the study, including Extreme Gradient Boosting (XGBoost) model, Logistic Regression (LR) model, RandomForest (RF) model, Multilayer Perceptron (MLP) model, and Support Vector Machine (SVM) model. Afterwards, the performance of the obtained prediction models was evaluated by area under the curve (AUC), accuracy, sensitivity, specificity, F1 score, and Kappa. The prediction performances of the models based on machine learning are as follows: XGBoost model (AUC = 0.979, accuracy = 0.931), LR model (AUC = 0.821, accuracy = 0.758), RF model (AUC = 0.970, accuracy = 0.921), MLP model (AUC = 0.830, accuracy = 0.756), SVM model (AUC = 0.713, accuracy = 0.661). On our data set, the XGBoost model has the best performance. However, the model still needs external verification research before clinical application.
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Affiliation(s)
- Conghui Wei
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Jialiang Wang
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Pengfei Yu
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Ang Li
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Ziying Xiong
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Zhen Yuan
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China
| | - Lingling Yu
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China.
| | - Jun Luo
- Department of Rehabilitation Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, 330006, Jiangxi, People's Republic of China.
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Roy B, Cho JG, Baker L, Thomas L, Curnow J, Harvey JJ, Geenty P, Banerjee A, Lai K, Vicaretti M, Erksine O, Li J, Alasady R, Wong V, Tai JE, Thirunavukarasu C, Haque I, Chien J. Pulmonary embolism response teams. A description of the first 36-month Australian experience. Intern Med J 2024. [PMID: 38497689 DOI: 10.1111/imj.16363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/06/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND High/intermediate-risk pulmonary embolism (PE) confers increased risk of cardiovascular morbidity and mortality. International guidelines recommend the formation of a PE response team (PERT) for PE management because of the complexity of risk stratification and emerging treatment options. However, there are currently no available Australian data regarding outcomes of PE managed through a PERT. AIMS To analyse the clinical and outcome data of patients from an Australian centre with high/intermediate-risk PE requiring PERT-guided management. METHODS We performed a retrospective observational study of 75 consecutive patients with high/intermediate-risk PE who had PERT involvement, between August 2018 and July 2021. We recorded clinical and interventional data at the time of PERT and assessed patient outcomes up to 30 days from PERT initiation. We used unpaired t tests to compare right to left ventricular (RV/LV) ratios by computed tomography criteria or transthoracic echocardiogram (TTE) at baseline and after interventions. RESULTS Data were available for 74 patients. Initial computed tomography pulmonary angiography RV/LV ratio was increased at 1.65 ± 0.5 and decreased to 1.30 ± 0.29 following PERT-guided interventions (P < 0.001). TTE RV/LV ratio also decreased following PERT-guided management (1.09 ± 0.19 vs 0.93 ± 0.17; P < 0.001). 20% of patients had any bleeding complication, but two-thirds were mild, not requiring intervention. All-cause mortality was 6.8%, and all occurred within the first 7 days of admission. CONCLUSION The PERT model is feasible in a large Australian centre in managing complex and time-critical PE. Our data demonstrate outcomes comparable with existing published international PERT data. However, successful implementation at other Australian institutions may require adequate centre-specific resource availability and the presence of multispeciality input.
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Affiliation(s)
- Bapti Roy
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- School of Medical & Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Jin-Gun Cho
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Luke Baker
- Department of Radiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Liza Thomas
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Jennifer Curnow
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Haematology, Westmead Hospital, Sydney, New South Wales, Australia
| | - John J Harvey
- Department of Radiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Paul Geenty
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ashoke Banerjee
- Department of Intensive Care Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Kevin Lai
- Department of Emergency Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mauro Vicaretti
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
- Department of Vascular Surgery, Westmead Hospital, Sydney, New South Wales, Australia
| | - Odette Erksine
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jane Li
- Department of Radiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rafid Alasady
- Department of Radiology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Vanessa Wong
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jian E Tai
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | | | - Imran Haque
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
| | - Jimmy Chien
- Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, New South Wales, Australia
- Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
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40
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Murguia AR, Mukherjee D, Ojha C, Rajachandran M, Siddiqui TS, Nickel NP. Reduced-Dose Thrombolysis in Acute Pulmonary Embolism A Systematic Review. Angiology 2024; 75:208-218. [PMID: 37060258 DOI: 10.1177/00033197231167062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Pulmonary embolism (PE) is the third-leading cause of cardiovascular mortality and the second-leading cause of death in cancer patients. The clinical efficacy of thrombolysis for acute PE has been proven, yet the therapeutic window seems narrow, and the optimal dosing for pharmaceutical reperfusion therapy has not been established. Higher doses of systemic thrombolysis inevitably associated with an incremental increase in major bleeding risk. To date, there is no high-quality evidence regarding dosing and infusion rates of thrombolytic agents to treat acute PE. Most clinical trials have focused on thrombolysis compared with anticoagulation alone, but dose-finding studies are lacking. Evidence is now emerging that lower-dose thrombolytic administered through a peripheral vein is efficacious in accelerating thrombolysis in the central pulmonary artery and preventing acute right heart failure, with reduced risk for major bleeding. The present review will systematically summarize the current evidence of low-dose thrombolysis in acute PE.
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Affiliation(s)
- Adrian Rojas Murguia
- Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Chandra Ojha
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Manu Rajachandran
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Tariq S Siddiqui
- Division of Cardiovascular Medicine, Department of Internal Medicine, Health Sciences Center of El Paso, Texas, TX, USA
| | - Nils P Nickel
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center of El Paso, Texas, TX, USA
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Casey SD, Stubblefield WB, Luijten D, Klok FA, Westafer LM, Vinson DR, Kabrhel C. Addressing the rising trend of high-risk pulmonary embolism mortality: Clinical and research priorities. Acad Emerg Med 2024; 31:288-292. [PMID: 38129964 DOI: 10.1111/acem.14859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Deaths from high-risk pulmonary embolism (PE) appear to have increased in the US over the last decade. Modifiable risks contributing to this worrisome trend present opportunities for physicians, researchers, and healthcare policymakers to improve care. METHODS We sought to contextualize contemporary, high-risk PE epidemiology and examine clinical trials, quality improvement opportunities, and healthcare policy initiatives directed at reducing mortality. RESULTS We observed significant and modifiable excess mortality due to high-risk PE. We identified several opportunities to improve care including: (1) rapid translation of forthcoming data on reperfusion strategies into clinical practice; (2) improved risk stratification tools; (3) quality improvement initiatives to address presumptive anticoagulation practice gaps; and (3) adoption of health policy initiatives to establish pulmonary embolism response teams and address the social determinants of health. CONCLUSION Addressing knowledge and practice gaps in intermediate and high-risk PE management must be prioritized and informed by forthcoming high-quality data. Implementation efforts are needed to improve acute PE management and resolve treatment disparities.
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Affiliation(s)
- Scott D Casey
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Vallejo Medical Center, Vallejo, California, USA
| | - William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dieuwke Luijten
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Frederikus A Klok
- Department of Medicine-Thrombosis and Hemostasis, Leiden University Medicine Center, Leiden, Netherlands
| | - Lauren M Westafer
- Department of Emergency Medicine, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
- Department of Healthcare Delivery and Population Science, UMASS Chan Medical School-Baystate, Springfield, Massachusetts, USA
| | - David R Vinson
- Kaiser Permanente Division of Research, Oakland, California, USA
- The Kaiser Permanente CREST Network, Oakland, California, USA
- Department of Emergency Medicine, Kaiser Permanente Roseville Medical Center, Roseville, California, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Ismayl M, Ismayl A, Hamadi D, Aboeata A, Goldsweig AM. Catheter-directed thrombolysis versus thrombectomy for submassive and massive pulmonary embolism: A systematic review and meta-analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 60:43-52. [PMID: 37833203 DOI: 10.1016/j.carrev.2023.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/11/2023] [Accepted: 10/04/2023] [Indexed: 10/15/2023]
Abstract
INTRODUCTION Controversy surrounds the optimal therapy for submassive and massive pulmonary embolism (PE). We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus surgical and catheter-based thrombectomy in patients with submassive and massive PE. METHODS We searched PubMed, EMBASE, Cochrane, and Google Scholar for studies comparing outcomes of CDT versus thrombectomy in submassive and massive PE. Studies were identified and data were extracted by two independent reviewers. A random effects model was used to calculate risk ratios (RRs) with 95 % confidence intervals (CIs). Outcomes included in-hospital mortality, procedural complications, hospital and intensive care unit (ICU) length of stay (LOS), 30-day readmissions, and right ventricle/left ventricle (RV/LV) ratio improvement. RESULTS Eight observational studies with 1403 patients were included, of whom 50.0 % received CDT. Compared to thrombectomy, CDT was associated with significantly lower in-hospital mortality (RR 0.62; 95 % CI 0.43-0.89; p = 0.01) and similar rates of major bleeding (p = 0.61), blood transfusion (p = 0.41), stroke (p = 0.41), and atrial fibrillation (p = 0.71). The hospital and ICU LOS, 30-day readmissions, and degree of RV/LV ratio improvement were similar between the two strategies (all p > 0.1). In subgroup analyses, in-hospital mortality was similar between CDT and catheter-based thrombectomy (p = 0.48) but lower with CDT compared with surgical thrombectomy (p = 0.01). CONCLUSIONS In patients with submassive and massive PE, CDT was associated with similar in-hospital mortality compared to catheter-based thrombectomy, but lower in-hospital mortality compared to surgical thrombectomy. Procedural complications, LOS, 30-day readmissions, and RV/LV ratio improvement were similar between CDT and any thrombectomy. Randomized controlled trials are indicated to confirm our findings.
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Affiliation(s)
- Mahmoud Ismayl
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA.
| | - Ahmad Ismayl
- Department of Medicine, Northern General Hospital, Sheffield, UK
| | - Dana Hamadi
- Department of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Aboeata
- Department of Cardiovascular Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Andrew M Goldsweig
- Department of Cardiovascular Medicine, Baystate Medical Center and University of Massachusetts-Baystate, Springfield, MA, USA
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Bastas D, Brandão LR, Vincelli J, Wilson D, Perrem L, Guerra V, Wong G, Bentley RF, Tole S, Schneiderman JE, Amiri N, Williams S, Avila ML. Long-term outcomes of pulmonary embolism in children and adolescents. Blood 2024; 143:631-640. [PMID: 38134357 DOI: 10.1182/blood.2023021953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/06/2023] [Accepted: 11/06/2023] [Indexed: 12/24/2023] Open
Abstract
ABSTRACT Knowledge regarding the long-term consequences of pulmonary embolism (PE) in children is limited. This cohort study describes the long-term outcomes of PE in children who were followed-up at a single-center institution using a local protocol that included clinical evaluation, chest imaging, echocardiography, pulmonary function tests, and cardiopulmonary exercise tests at follow-up, starting 3 to 6 months after acute PE. Children objectively diagnosed with PE at age 0 to 18 years, who had ≥6 months of follow-up were included. Study outcomes consisted of PE resolution, PE recurrence, death, and functional outcomes (dyspnea, impaired pulmonary or cardiac function, impaired aerobic capacity, and post-PE syndrome). The frequency of outcomes was compared between patients with/without underlying conditions. In total, 150 patients were included; median age at PE was 16 years (25th-75th percentile, 14-17 years); 61% had underlying conditions. PE did not resolve in 29%, recurrence happened in 9%, and death in 5%. One-third of patients had at least 1 documented abnormal functional finding at follow-up (ventilatory impairments, 31%; impaired aerobic capacity, 31%; dyspnea, 26%; and abnormal diffusing capacity of the lungs to carbon monoxide, 22%). Most abnormalities were transient. When alternative explanations for the impairments were considered, the frequency of post-PE syndrome was lower, ranging between 0.7% and 8.5%. Patients with underlying conditions had significantly higher recurrence, more pulmonary function and ventilatory impairments, and poorer exercise capacity. Exercise intolerance was, in turn, most frequently because of deconditioning than to respiratory or cardiac limitation, highlighting the importance of physical activity promotion in children with PE.
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Affiliation(s)
- Denise Bastas
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Leonardo R Brandão
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jennifer Vincelli
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - David Wilson
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lucy Perrem
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Vitor Guerra
- Division of Cardiology, The Hospital for Sick Children, Toronto, ON, Canada
| | - Gina Wong
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Robert F Bentley
- Faculty of Kinesiology & Physical Education, University of Toronto, Toronto, ON, Canada
| | - Soumitra Tole
- Division of Hematology/Oncology, Department of Pediatrics, Children's Hospital, London Health Sciences Centre, London, ON, Canada
- Department of Pediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Jane E Schneiderman
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Nour Amiri
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Suzan Williams
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
| | - M Laura Avila
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Hematology/Oncology, The Hospital for Sick Children, Toronto, ON, Canada
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Gill KPS, O'Brien DP, Soverow JE. Use of Ultrasound-Assisted, Catheter-Directed Thrombolysis in a Patient With High-Risk Pulmonary Embolism. Tex Heart Inst J 2024; 51:e238235. [PMID: 38317350 DOI: 10.14503/thij-23-8235] [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: 02/07/2024]
Abstract
High-risk pulmonary embolism (PE) is a complex clinical entity associated with high mortality rates. Ultrasound-assisted, catheter-directed thrombolysis, typically used for intermediate-risk PE, may be a viable treatment approach for high-risk PE, particularly in patients at increased risk for major bleeding. This report describes a case in which ultrasound-assisted, catheter-directed thrombolysis was successfully used to treat high-risk PE in a female patient with extensive peritoneal metastases from gastric adenocarcinoma. Other examples from the literature, in which ultrasound-assisted, catheter-directed thrombolysis was used to treat high-risk PE, are also provided.
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Affiliation(s)
- Karam P S Gill
- Department of Internal Medicine, Olive View-University of California Los Angeles Medical Center, Sylmar, California
| | - Daniel P O'Brien
- Department of Cardiology, Olive View-University of California Los Angeles Medical Center, Sylmar, California
| | - Jonathan E Soverow
- Department of Cardiology, Olive View-University of California Los Angeles Medical Center, Sylmar, California
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Villalba LM, Bayat I, Dubenec S, Puckridge P, Thomas S, Varcoe R, Vasudevan T, Tripathi R. Review of the literature supporting international clinical practice guidelines on iliac venous stenting and their applicability to Australia and New Zealand practice. J Vasc Surg Venous Lymphat Disord 2024:101843. [PMID: 38316289 DOI: 10.1016/j.jvsv.2024.101843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/25/2024] [Accepted: 01/28/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND The overall goal of this report is to provide a high-level, practical approach to managing venous outflow obstruction (VOO). METHODS A group of vascular surgeons from Australia and New Zealand with specific interest, training, and experience in the management of VOO were surveyed to assess current local practices. The results were analyzed and areas of disagreement identified. After this, the group performed a literature review of consensus guidelines published by leading international organizations focused on the management of chronic venous disease, namely, the Society for Vascular Surgery, American Venous Forum, European Society for Vascular Surgery, American Vein and Lymphatic Society, Cardiovascular and Interventional Radiology Society of Europe, and American Heart Association. These guidelines were compared against the consensus statements obtained through the surveys to determine how they relate to Australian and New Zealand practice. In addition, selected key studies, reviews, and meta-analyses on venous stenting were discussed and added to the document. A selection of statements with >75% agreement was voted on, and barriers to the guideline's applicability were identified. The final recommendations were further reviewed and endorsed by another group of venous experts. RESULTS The document addresses two key areas: patient selection and technical aspects of venous stenting. Regarding patient selection, patients with clinically relevant VOO, a Clinical-Etiologic-Anatomic-Physiologic score of ≥3 or a Venous Clinical Severity Score for pain of ≥2, or both, including venous claudication, with evidence of >50% stenosis should be considered for venous stenting (Level of Recommendation Ib). Patients with chronic pelvic pain, deep dyspareunia, postcoital pain affecting their quality of life, when other causes have been ruled out, should also be considered for venous stenting (Level of Recommendation Ic). Asymptomatic patients should not be offered venous stenting (Level of Recommendation IIIc). Patients undergoing thrombus removal for acute iliofemoral deep vein thrombosis, in whom a culprit stenotic lesion of >50% has been uncovered, should be considered for venous stenting (Level of Recommendation Ib). CONCLUSIONS Patients with VOO have been underdiagnosed and undertreated for decades; however, in recent years, interest from physicians and industry has grown substantially. International guidelines aimed at developing standards of care to avoid undertreating and overtreating patients are applicable to Australia and New Zealand practice and will serve as an educational platform for future developments.
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Affiliation(s)
- Laurencia Maria Villalba
- Vascular Surgery, University of Wollongong, Wollongong, New South Wales, Australia; Vascular Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia.
| | - Iman Bayat
- Vascular Surgery, The Northern Hospital, Melbourne, Victoria, Australia
| | - Steven Dubenec
- Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Philip Puckridge
- Vascular Surgery, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Shannon Thomas
- Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Ramon Varcoe
- Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia; Vascular Surgery, University of New South Wales, Sydney, Australia
| | | | - Ramesh Tripathi
- Vascular Surgery, University of Queensland, Brisbane, Australia
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Woo C, Sun W, Thein P, Chong MY, Tan E, Junckerstorff R. Preemptive anticoagulation of pulmonary embolism. Intern Med J 2024; 54:242-249. [PMID: 37490553 DOI: 10.1111/imj.16174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 06/06/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a life-threatening disease where preemptive anticoagulation is recommended by guidelines for patients with intermediate to high pretest risk of PE. AIMS The primary objective of our study was to describe the use of preemptive anticoagulation from the emergency department (ED) or inpatient wards stratified by risk assessment score. METHODS We performed a retrospective observational cohort study of consecutive patients undergoing computed tomography pulmonary angiography (CTPA) for investigation of PE. Patients were classified as either ED patients or hospital ward patients based on where the CTPA was requested. The pretest risk of PE was calculated using the Revised Geneva Score (RGS) and patients were divided into low and intermediate to high risk. RESULTS A total of 392 consecutive patients who underwent CTPA at Monash Health were reviewed. There were 108 (27.6%) patients who were categorised as low risk (RGS 0-3) and 284 (72.4%) categorised as intermediate to high risk (RGS >3). There were 29 (7.4%) patients overall who received preemptive anticoagulation. Diagnostic yield of CTPA in the ED was low, with only four of 144 (2.8%) CTPA scans positive for PE. The yield of CTPA was higher in ward patients, with 63 of 248 (25.4%) being diagnostic of PE. CONCLUSIONS The use of preemptive anticoagulation for suspected PE was uncommon and was not influenced by the pretest probability of PE as determined by a validated clinical prediction tool. This may reflect concerns regarding haemorrhagic complications without any clear evidence of benefit. Diagnostic yield of CTPA performed in the ED was low.
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Affiliation(s)
- Christopher Woo
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Wei Sun
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Paul Thein
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Mae Yi Chong
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
| | - Ethan Tan
- Department of Medicine, Monash Health, Melbourne, Victoria, Australia
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Westafer LM, Long B, Gottlieb M. In reply. Ann Emerg Med 2024; 83:182-183. [PMID: 38245236 DOI: 10.1016/j.annemergmed.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 01/22/2024]
Affiliation(s)
- Lauren M Westafer
- Department of Emergency Medicine, Healthcare Delivery and Population Science, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL
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48
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Pawar SG, Khan N, Salam A, Joshi M, Saravanan PB, Pandey S. The association of Pulmonary Hypertension and right ventricular systolic function - updates in diagnosis and treatment. Dis Mon 2024; 70:101635. [PMID: 37734967 DOI: 10.1016/j.disamonth.2023.101635] [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: 09/23/2023]
Abstract
Right ventricular (RV) systolic function is an essential but neglected component in cardiac evaluation, and its importance to the contribution to overall cardiac function is undermined. It is not only sensitive to the effect of left heart valve disease but is also more sensitive to changes in pressure overload than the left ventricle. Pulmonary Hypertension is the common and well-recognized complication of RV systolic dysfunction. It is also the leading cause of pulmonary valve disease and right ventricular dysfunction. Patients with a high pulmonary artery pressure (PAP) and a low RV ejection fraction have a seven-fold higher risk of death than heart failure patients with a normal PAP and RV ejection fraction. Furthermore, it is an independent predictor of survival in these patients. In this review, we examine the association of right ventricular systolic function with Pulmonary Hypertension by focusing on various pathological and clinical manifestations while assessing their impact. We also explore new 2022 ESC/ERS guidelines for diagnosing and treating right ventricular dysfunction in Pulmonary Hypertension.
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Affiliation(s)
| | - Nida Khan
- Jinnah Sindh Medical University, Pakistan
| | - Ajal Salam
- Government Medical College Kottayam, Kottayam, Kerala, India
| | - Muskan Joshi
- Tbilisi State Medical University, Tbilisi, Georgia
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Bikdeli B, Sadeghipour P, Lou J, Bejjani A, Khairani CD, Rashedi S, Lookstein R, Lansky A, Vedantham S, Sobieszczyk P, Mena-Hurtado C, Aghayev A, Henke P, Mehdipoor G, Tufano A, Chatterjee S, Middeldorp S, Wasan S, Bashir R, Lang IM, Shishehbor MH, Gerhard-Herman M, Giri J, Menard MT, Parikh SA, Mazzolai L, Moores L, Monreal M, Jimenez D, Goldhaber SZ, Krumholz HM, Piazza G. Developmental or Procedural Vena Cava Interruption and Venous Thromboembolism: A Review. Semin Thromb Hemost 2024. [PMID: 38176425 DOI: 10.1055/s-0043-1777991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
The inferior vena cava (IVC) and superior vena cava are the main conduits of the systemic venous circulation into the right atrium. Developmental or procedural interruptions of vena cava might predispose to stasis and deep vein thrombosis (DVT) distal to the anomaly and may impact the subsequent rate of pulmonary embolism (PE). This study aimed to review the various etiologies of developmental or procedural vena cava interruption and their impact on venous thromboembolism. A systematic search was performed in PubMed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines per each clinical question. For management questions with no high-quality evidence and no mutual agreements between authors, Delphi methods were used. IVC agenesis is the most common form of congenital vena cava interruption, is associated with an increased risk of DVT, and should be suspected in young patients with unexpected extensive bilateral DVT. Surgical techniques for vena cava interruption (ligation, clipping, and plication) to prevent PE have been largely abandoned due to short-term procedural risks and long-term complications, although survivors of prior procedures are occasionally encountered. Vena cava filters are now the most commonly used method of procedural interruption, frequently placed in the infrarenal IVC. The most agreed-upon indication for vena cava filters is for patients with acute venous thromboembolism and coexisting contraindications to anticoagulation. Familiarity with different forms of vena cava interruption and their local and systemic adverse effects is important to minimize complications and thrombotic events.
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Affiliation(s)
- Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Cardiovascular Research Foundation (CRF), New York, New York
| | - Parham Sadeghipour
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Clinical Trial Center, Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Junyang Lou
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Antoine Bejjani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Candrika D Khairani
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sina Rashedi
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Robert Lookstein
- Division of Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexandra Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
| | - Piotr Sobieszczyk
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Ayaz Aghayev
- Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Peter Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ghazaleh Mehdipoor
- Cardiovascular Research Foundation (CRF), New York, New York
- Center for Evidence-based Imaging, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonella Tufano
- Department of Clinical Medicine and Surgery, Federico II University Hospital, Naples, Italy
| | - Saurav Chatterjee
- Division of Cardiology, Department of Medicine, Zucker School of Medicine, New York, New York
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Suman Wasan
- University of North Carolina, Chapel Hill, North Carolina
| | - Riyaz Bashir
- Departement of Cardiovascular Diseases, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Irene M Lang
- Department of Internal Medicine II, Cardiology and Center of Cardiovascular Medicine, Medical University of Vienna, Vienna, Austria
| | - Mehdi H Shishehbor
- University Hospitals Heath System, Harrington Heart and Vascular Institute, Cleveland, Ohio
| | - Marie Gerhard-Herman
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Jay Giri
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Division, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Matthew T Menard
- Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sahil A Parikh
- Cardiovascular Research Foundation (CRF), New York, New York
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
| | - Lisa Moores
- Department of Medicine, Uniformed Services University of Health Sciences, Bethesda, Maryland
| | | | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harlan M Krumholz
- YNHH/Yale Center for Outcomes Research and Evaluation (CORE), New Haven, Connecticut
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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50
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Argyriou A, Vohra H, Chan J, Ahmed EM, Rajakaruna C, Angelini GD, Fudulu DP. Incidence and outcomes of surgical pulmonary embolectomy in the UK. Br J Surg 2024; 111:znae003. [PMID: 38230762 PMCID: PMC11167207 DOI: 10.1093/bjs/znae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/06/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Surgical pulmonary embolectomy is rarely used for the treatment of massive acute pulmonary embolism. The aim of this study was to assess the incidence and outcomes of this operation by undertaking a retrospective analysis of a large national registry in the UK. METHODS All acute pulmonary embolectomies performed between 1996 and 2018 were captured in the National Institute of Cardiovascular Outcomes Research central database. Trends in the number of operations performed during this interval and reported in-hospital outcomes were analysed retrospectively. Multivariable logistic regression was used to identify independent risk factors for in-hospital death. RESULTS All 256 patients treated surgically for acute pulmonary embolism during the study interval were included in the analysis. Median age at presentation was 54 years, 55.9% of the patients were men, 48.0% had class IV heart failure symptoms, and 37.5% had preoperative cardiogenic shock. The median duration of bypass was 73 min, and median cross-clamp time was 19 min. Cardioplegic arrest was used in 53.1% of patients. The median duration of hospital stay was 11 days. The in-hospital mortality rate was 25%, postoperative stroke occurred in 5.4%, postoperative dialysis was required in 16%, and the reoperation rate for bleeding was 7.5%. Risk-adjusted multivariable analysis revealed cardiogenic shock (OR 2.54, 95% c.i. 1.05 to 6.21; P = 0.038), preoperative ventilation (OR 5.85, 2.22 to 16.35; P < 0.001), and duration of cardiopulmonary bypass exceeding 89 min (OR 7.82, 3.25 to 20.42; P < 0.001) as significant independent risk factors for in-hospital death. CONCLUSION Surgical pulmonary embolectomy is rarely performed in the UK, and is associated with significant mortality and morbidity. Preoperative ventilation, cardiogenic shock, and increased duration of bypass were significant predictors of in-hospital death.
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Affiliation(s)
- Amerikos Argyriou
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Hunaid Vohra
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Jeremy Chan
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Eltayeb Mohamed Ahmed
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Cha Rajakaruna
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Gianni Davide Angelini
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Daniel Paul Fudulu
- Bristol Heart Institute, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
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