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Rozenbaum Z. Reply: Improving Outcomes of Unstable Patients With Acute Pulmonary Embolism. JACC. ADVANCES 2024; 3:101067. [PMID: 39055271 PMCID: PMC11269893 DOI: 10.1016/j.jacadv.2024.101067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Affiliation(s)
- Zach Rozenbaum
- Department of Cardiology, Tulane University, 131 S. Robertson Street, New Orleans, Louisiana 70112, USA.
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2
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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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3
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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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4
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Ubaldi N, Krokidis M, Rossi M, Orgera G. Endovascular treatments of acute pulmonary embolism in the post-fibrinolytic era: an up-to-date review. Insights Imaging 2024; 15:122. [PMID: 38767729 PMCID: PMC11106225 DOI: 10.1186/s13244-024-01694-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 04/03/2024] [Indexed: 05/22/2024] Open
Abstract
Pulmonary embolism (PE) is a significant contributor to global cardiovascular-related mortality that mainly depends on the severity of the event. The treatment approach for intermediate and high-risk PE remains a topic of debate due to the fine balance between hemodynamic deterioration and bleeding risk. The initial treatment choice for intermediate-risk PE with hemodynamic deterioration and high-risk PE is historically systemic thrombolysis, but this approach is not always effective and carries a notable risk of severe bleeding. For such patients, various interventional treatments have been introduced to clinical practice, including catheter-directed lysis (CDL), ultrasound-assisted CDL, pharmacomechanical CDL, and aspiration thrombectomy. However, the optimal treatment approach remains uncertain. Encouraging outcomes have been presented assessing the novel endovascular treatments, in terms of reducing right ventricular dysfunction and improving hemodynamic stability, opening the possibility of using these devices to prevent hemodynamic instability in less severe cases. However, ongoing randomized trials that assess the efficacy and the association with mortality, especially for aspiration devices, have not yet published their final results. This article aims to offer a comprehensive update of the available catheter-directed therapies for PE, with a focus on novel mechanical thrombectomy techniques, assessing their safety and efficacy, after comparison to the conventional treatment. CRITICAL RELEVANCE STATEMENT: This is a comprehensive review of the indications of use, techniques, and clinical outcomes of the most novel endovascular devices for the treatment of pulmonary embolism. KEY POINTS: Mechanical thrombectomy is an effective tool for patients with PE. Aspiration devices prevent hemodynamic deterioration. Catheter directed therapy reduces bleeding complications.
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Affiliation(s)
- Nicolò Ubaldi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Miltiadis Krokidis
- 1st Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece.
| | - Michele Rossi
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
| | - Gianluigi Orgera
- Department of Radiology, Sant'Andrea University Hospital La Sapienza, School of Medicine and Psychology, "Sapienza" - University of Rome, Rome, Italy
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5
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Mergoum AM, Rhone AR, Larson NJ, Dries DJ, Blondeau B, Rogers FB. A Guide to the Use of Vasopressors and Inotropes for Patients in Shock. J Intensive Care Med 2024:8850666241246230. [PMID: 38613381 DOI: 10.1177/08850666241246230] [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: 04/14/2024]
Abstract
Shock is a life-threatening circulatory failure that results in inadequate tissue perfusion and oxygenation. Vasopressors and inotropes are vasoactive medications that are vital in increasing systemic vascular resistance and cardiac contractility, respectively, in patients presenting with shock. To be well versed in using these agents is an important skill to have in the critical care setting where patients can frequently exhibit symptoms of shock. In this review, we will discuss the pathophysiological mechanisms of shock and evaluate the current evidence behind the management of shock with an emphasis on vasopressors and inotropes.
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Affiliation(s)
| | | | | | - David J Dries
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
| | - Benoit Blondeau
- Department of Surgery, Regions Hospital, Saint Paul, MN, USA
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Truong RD, Cheyney S, Vo M, Garcia J, Desai NN, Kropf J, Hassanein H. Successful Treatment of Massive Pulmonary Embolism in Pregnancy with Catheter-Directed Embolectomy. AJP Rep 2024; 14:e140-e144. [PMID: 38736706 PMCID: PMC11087143 DOI: 10.1055/a-2299-4026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 03/27/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Pulmonary embolism (PE) is associated with approximately 10.5% of maternal deaths in the United States. Despite heightened awareness of its mortality potential, there islittle data available to guide its management in pregnancy. We present the case of a massive PE during gestation successfully treated with catheter-directed embolectomy. Case Presentation A 37-year-old G2P1001 presented with a syncopal episode preceded by dyspnea and chest pain. Upon presentation, she was hypotensive, tachycardiac, and hypoxic. Imaging showed an occlusive bilateral PE, right heart strain, and a possible intrauterine pregnancy. Beta-human chorionic gonadotropin was positive. She was taken emergently for catheter-directed embolectomy. Her condition immediately improved afterward. Postprocedure pelvic ultrasound confirmed a viable intrauterine pregnancy at 10 weeks gestation. She was discharged with therapeutic enoxaparin and gave birth to a healthy infant at 38 weeks gestation. Conclusion Despite being the gold standard for PE treatment in nonpregnant adults, systemic thrombolysis is relatively contraindicated in pregnancy due to concern for maternal or fetal hemorrhage. Surgical or catheter-based thrombectomies are rarely recommended. Limited alternative options force their consideration, particularly in a hemodynamically unstable patient. Catheter-directed embolectomy can possibly bypass such complications. Our case exemplifies the consideration of catheter-directed embolectomy as the initial treatment modality of a hemodynamically unstable gestational PE.
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Affiliation(s)
- Rachel D. Truong
- Department of Internal Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Sarah Cheyney
- Department of Pulmonary and Critical Care Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Mai Vo
- Department of Pulmonary and Critical Care Medicine, Orlando Regional Medical Center, Orlando, Florida
| | - Joel Garcia
- Department of Interventional Cardiology, Orlando Regional Medical Center, Orlando, Florida
| | - Neeraj N. Desai
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Winnie Palmer Hospital, Orlando, Florida
| | - Jacqueline Kropf
- Department of Hematology and Medical Oncology, Orlando Health Cancer Institute, Orlando, Florida
| | - Hatem Hassanein
- Department of Hematology and Medical Oncology, Orlando Health Cancer Institute, Orlando, Florida
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7
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Rössler J, Cywinski JB, Argalious M, Ruetzler K, Khanna S. Anesthetic management in patients having catheter-based thrombectomy for acute pulmonary embolism: A narrative review. J Clin Anesth 2024; 92:111281. [PMID: 37813080 DOI: 10.1016/j.jclinane.2023.111281] [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: 07/25/2023] [Revised: 08/25/2023] [Accepted: 09/30/2023] [Indexed: 10/11/2023]
Abstract
Pulmonary embolism is the third leading cause of cardiovascular death. Novel percutaneous catheter-based thrombectomy techniques are rapidly becoming popular in high-risk pulmonary embolism - especially in the presence of contraindications to thrombolysis. The interventional nature of these procedures and the risk of sudden cardiorespiratory compromise requires the presence of an anesthesiologist. Facilitating catheter-based thrombectomy can be challenging since qualifying patients are often critically ill. The purpose of this narrative review is to provide guidance to anesthesiologists for the assessment and management of patients having catheter-based thrombectomy for acute pulmonary embolism. First, available techniques for catheter-based thrombectomy are reviewed. Then, we discuss definitions and application of common risk stratification tools for pulmonary embolism, and how to assess patients prior to the procedure. An adjudication of risks and benefits of anesthetic strategies for catheter-based thrombectomy follows. Specifically, we give guidance and rationale for use monitored anesthesia care and general anesthesia for these procedures. For both, we review strategies for assessing and mitigating hemodynamic perturbations and right ventricular dysfunction, ranging from basic monitoring to advanced inodilator therapy. Finally, considerations for management of right ventricular failure with mechanical circulatory support are discussed.
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Affiliation(s)
- Julian Rössler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jacek B Cywinski
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Maged Argalious
- Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kurt Ruetzler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Sandeep Khanna
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA; Department of Cardiothoracic and Vascular Anesthesia, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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Barca-Hernando M, Jara-Palomares L. Pulmonary embolism: a practical approach to update risk stratification and treatment decisions based on the guidelines. Expert Rev Respir Med 2023; 17:1151-1158. [PMID: 38133539 DOI: 10.1080/17476348.2023.2298826] [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: 11/09/2023] [Accepted: 12/20/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a prevalent condition with a substantial morbi-mortality worldwide. Proper risk stratification of PE is essential for identifying the most suitable therapeutic strategy and the optimal care setting for the patient. This process entails evaluating various factors, including symptoms, comorbidities, and right heart dysfunction. AREAS COVERED This review assesses the tools and methods utilized to identify and stratify individuals based on the probability of developing deterioration or death related to PE. Current guidelines divide PE into three groups: high-risk (previously termed massive) PE, intermediate-risk (sub-massive) PE, and low-risk PE. Various risk scores, such as the simplified pulmonary embolism severity index (sPESI), Bova score, and the FAST score (incorporating Heart-Fatty Acid binding protein [H-ABP], Syncope, Tachycardia), aid in identifying patients at higher risk. Additionally, the Hestia score is instrumental in pinpointing low-risk patients. EXPERT OPINION Presently, there is a dearth of high-quality frameworks for the optimal management and treatment of PE patients at risk of hemodynamic collapse. A consortium of experts is in the process of formulating a new conceptual model for risk stratification, taking into account a comprehensive array of variables and outcomes to facilitate more individualized management of acute PE.
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Affiliation(s)
| | - Luis Jara-Palomares
- Respiratory Department, Hospital Virgen del Rocio, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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Osmani N, Marinaro J, Guliani S. Life-threatening pulmonary embolism: overview and management. Int Anesthesiol Clin 2023; 61:35-42. [PMID: 37622318 DOI: 10.1097/aia.0000000000000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Nizar Osmani
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico
| | - Jonathan Marinaro
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
| | - Sundeep Guliani
- Center for Adult Critical Care, University of New Mexico, Albuquerque, New Mexico
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Barca-Hernando M, Jara-Palomares L. When should we involve interventional radiology in the management of acute pulmonary embolism? Breathe (Sheff) 2023; 19:230085. [PMID: 37719239 PMCID: PMC10501706 DOI: 10.1183/20734735.0085-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/27/2023] [Indexed: 09/19/2023] Open
Abstract
Pulmonary embolism (PE) is a common disease associated with high morbidity and mortality. Currently, guidelines recommend systemic thrombolysis in patients with haemodynamic instability (high-risk PE) or patients with intermediate-high-risk PE with haemodynamic deterioration. Nevertheless, more than half of high-risk PE patients do not receive systemic thrombolysis due to a perceived increased risk of bleeding. In these cases, percutaneous catheter-directed therapy (CDT) or surgical embolectomy should be considered. CDT has emerged and appears to be an effective alternative in treating PE, with a hypothetical lower risk of bleeding than systemic thrombolysis, acting directly in the thrombus with a much lower dose of thrombolytic drug or even without thrombolytic therapy. CDT techniques include catheter-directed clot aspiration or fragmentation, mechanical embolectomy, local thrombolysis, and combined pharmaco-mechanical approaches. A few observational prospective studies have demonstrated that CDT improves right ventricular function with a low rate of haemorrhage. Nevertheless, the evidence from randomised controlled trials is scarce. Here we review different scenarios where CDT may be useful and trials ongoing in this field. These results may change the upcoming guidelines for management and treatment of PE, establishing CDT as a recommended treatment in patients with acute intermediate-high-risk PE.
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Affiliation(s)
| | - Luis Jara-Palomares
- Respiratory Department, Hospital Virgen del Rocio, Sevilla, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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11
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Trivedi D, Minkin R. Mechanical Thrombectomy of a Submassive Pulmonary Embolism in the Second Trimester of Pregnancy. Cureus 2023; 15:e41578. [PMID: 37554617 PMCID: PMC10406550 DOI: 10.7759/cureus.41578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/08/2023] [Indexed: 08/10/2023] Open
Abstract
Venous thromboembolism (VTE) represents a potentially severe and infrequent complication that can occur in the pregnant population. The nuance in recognizing and diagnosing this condition can be quite difficult due to the changes that occur during pregnancy. This case highlights the importance of diagnosing pulmonary embolism in pregnancy, classifying the degree of disease, and determining the best treatment for both mother and fetus. Although rare, early diagnosis and treatment are crucial in order to reduce morbidity and mortality.
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Affiliation(s)
- Dhaval Trivedi
- Department of Internal Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
| | - Ruth Minkin
- Department of Pulmonary and Critical Care Medicine, NewYork-Presbyterian Brooklyn Methodist Hospital, New York City, USA
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12
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Bigdelu L, Daloee MH, Emadzadeh M, Parsa L, Najafi M, Baradaran Rahimi V. Comparison of echocardiographic pulmonary flow Doppler markers in patients with massive or submassive acute pulmonary embolism and control group: A cross-sectional study. Health Sci Rep 2023; 6:e1249. [PMID: 37152221 PMCID: PMC10158783 DOI: 10.1002/hsr2.1249] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023] Open
Abstract
Background and Aims Computed tomography angiography (CTA) is the gold standard for the diagnosis of massive (MPE) and submassive pulmonary embolism (SMPE). Ultrasound has not been accepted as a diagnostic tool. We aim to evaluate the pattern of pulmonary Doppler echocardiography in patients with pulmonary embolism (PE). Methods From 2020 to 2022, 30 patients with acute MPE or SMPE confirmed by CTA and normal pulmonary pressures were selected. A control group was created with 30 individuals without PE. All patients had an echocardiography Doppler study of the pulmonary flow with a focus on early systolic notching (ESN), McConnell's (MC) sign, Right ventricular outflow tract velocity time integral (RVOT VTI), segmental thickness variability (STV), right ventricular end-diastolic diameter (RVEDD), tricuspid regurgitation (TR) gradient, pulmonary artery pressure (PAP), and acceleration (AT) or ejection time (ET). Results ESN was identified in 96.6% of PE patients and 0% of the control group (p < 0.001). In comparison with the control group, STV (p < 0.001), RVOT VTI (p < 0.001), ET (p = 0.04), and AT (p < 0.001) values were lower in patients with PE while RVEDD, TR gradient, PAP, ESN, MC sign, and d-shape were higher (p < 0.001). Identification of the ESN pattern and AT/ET < 0.4 showed excellent predictive ability for MPE and SMPE with a sensitivity of 97.0% and 100%, specificity of 99.0% and 97%, and an area under the ROC curve of 0.967 (95% CI 0.914-1.00) and 0.933 (95% CI 0.844-1.00), respectively. Conclusion Doppler echocardiography with particular attention to ESN, may be a suitable noninvasive method for the diagnosis of MPE and SMPE. Further studies with more sample sizes are needed to confirm its diagnostic benefit.
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Affiliation(s)
- Leila Bigdelu
- Vascular and Endovascular Surgery Research CenterMashhad University of Medical SciencesMashhadIran
| | - Mahdi Hasanzadeh Daloee
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Maryam Emadzadeh
- Clinical Research Development Unit, Ghaem HospitalMashhad University of Medical SciencesMashhadIran
| | - Leila Parsa
- Edward Via College of Osteopathic MedicineBlacksburgVirginiaUSA
| | - Mahnaz Najafi
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Vafa Baradaran Rahimi
- Department of Cardiovascular Diseases, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
- Pharmacological Research Center of Medicinal PlantsMashhad University of Medical SciencesMashhadIran
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13
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Patel PB, Ramamurthy S. Massive Life-Threatening Saddle Pulmonary Embolism in a Healthy 28-Year-Old. Cureus 2023; 15:e37789. [PMID: 37213943 PMCID: PMC10198669 DOI: 10.7759/cureus.37789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2023] [Indexed: 05/23/2023] Open
Abstract
When Virchow's triad is disrupted, a deep vein thrombosis (DVT) can often occur and progress into a pulmonary embolism, and in rare cases, a saddle pulmonary embolism. This 28-year-old male patient showed up at the emergency department (ED) with shortness of breath, chest palpitations, and right calf pain. Additional imaging showed a massive saddle pulmonary embolism, and he was taken to immediate right femoral catheterization for thrombectomy. Though this patient presents with no known risk factors in his history or workup, he stretches the predefined boundaries with his cavalier presentation.
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Affiliation(s)
- Prachi B Patel
- Department of Cardiology, Philadelphia College of Osteopathic Medicine, Suwanee, USA
| | - Suresh Ramamurthy
- Department of Cardiology, Wellstar North Fulton Hospital, Roswell, USA
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14
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George TJ, Sheasby J, Sawhney R, DiMaio JM, Afzal A, Gable D, Sayfo S. Extracorporeal membrane oxygenation for large pulmonary emboli. Proc AMIA Symp 2023; 36:314-317. [PMID: 37091759 PMCID: PMC10120470 DOI: 10.1080/08998280.2023.2171699] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Massive and submassive pulmonary emboli (PE) are increasingly being treated with percutaneous lytic and embolectomy procedures. While these procedures are overwhelmingly safe, patients with significant right ventricular strain are at risk for hemodynamic compromise requiring extracorporeal membrane oxygenation (ECMO). We conducted a retrospective study of all patients requiring ECMO support for PE from 2014 through 2022. The primary outcome was survival. Secondary outcomes included commonly encountered ECMO complications. From 2014 to 2022, 10 patients with submassive or massive PE required ECMO support. All 10 patients (100%) had right ventricular strain on echocardiography, 7 (70%) had a saddle PE, and 3 (30%) had extensive bilateral PE. Six (60%) patients required cardiopulmonary resuscitation prior to ECMO cannulation, and 4 (40%) were undergoing cardiopulmonary resuscitation while being cannulated. Nine (90%) patients were placed on venoarterial ECMO through the femoral vessels, while 1 (10%) was cannulated with right atrial to pulmonary artery ECMO. The median duration of support was 4 [3-8] days. During their course, 5 patients underwent percutaneous embolectomy, 1 underwent surgical embolectomy, and 4 underwent percutaneous lytic therapy. All patients (100%) survived to ECMO decannulation, and 6 (60%) survived to discharge. With a mean follow-up of 496 days, there were no postdischarge mortalities. In conclusion, although therapy for large PE is well tolerated, a small number of patients will experience periprocedural hemodynamic collapse requiring ECMO support. ECMO for PE patients is associated with acceptable morbidity and mortality. Further investigation is warranted to better characterize which patients are likely to require ECMO support.
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Affiliation(s)
- Timothy J. George
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Jenelle Sheasby
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Rahul Sawhney
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - J. Michael DiMaio
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Aasim Afzal
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Dennis Gable
- Vascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Sameh Sayfo
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
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Wahood W, Sista AK, Paul JD, Ahmed O. Unplanned 30-Day Readmissions after Management of Submassive and Massive Acute Pulmonary Embolism: Catheter-Directed versus Systemic Thrombolysis. J Vasc Interv Radiol 2023; 34:116-123.e14. [PMID: 36167297 DOI: 10.1016/j.jvir.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 08/03/2022] [Accepted: 09/18/2022] [Indexed: 01/04/2023] Open
Abstract
PURPOSE To compare 30-day readmission and in-hospital outcomes from the Nationwide Readmissions Database (NRD) for catheter-directed thrombolysis (CDT) versus systemic intravenous thrombolysis (IVT) as treatments for acute submassive or massive pulmonary embolism (PE). MATERIALS AND METHODS The NRD was queried from 2016 to 2019 for adult patients with nonseptic acute PE who underwent IVT or CDT. Massive PE was distinguished from submassive PE if patients had concurrent International Classification of Diseases (ICD-10) codes corresponding to mechanical ventilation, vasopressors, or shock. Propensity score-matched analysis was conducted to infer the association of CDT versus IVT in unplanned 30-day readmissions, nonroutine discharge, gastrointestinal bleeding (GIB), and intracranial hemorrhage (ICH). These results are demonstrated as average treatment effects (ATEs) of IVT compared with those of CDT. RESULTS A total of 37,116 patients with acute PE were studied; 18,702 (50.3%) underwent CDT, and 18,414 (49.7%) underwent IVT. A total of 2,083 (11.1%) and 3,423 (18.6%) were massive PEs in the 2 groups, respectively (P < .001). The ATE of IVT was higher than that of CDT regarding unplanned 30-day readmissions (ATE, 0.019; P < .001), GIB (ATE, 0.012; P < .001), ICH (ATE, 0.003; P = .017), and nonroutine discharge (ATE, 0.022; P = .006). The subgroup analysis of patients with submassive PE demonstrated that IVT had a higher ATE regarding unplanned 30-day readmission (ATE, 0.028; P < .001), GIB (ATE, 0.008; P = .003), ICH (ATE, 0.002; P = .035), and nonroutine discharge (ATE, 0.019; P = .022) than CDT. CONCLUSIONS CDT had a lower likelihood of unplanned 30-day readmissions, including when stratified by a submassive PE subtype. Additionally, adverse events, including ICH and GIB, were more likely among patients who received IVT than among those who received CDT.
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Affiliation(s)
- Waseem Wahood
- Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Davie, Florida. https://twitter.com/waseemwahood
| | - Akhilesh K Sista
- Division of Vascular and Interventional Radiology, Department of Radiology, New York University Grossman School of Medicine, New York, New York
| | - Jonathan D Paul
- Department of Interventional Cardiology, University of Chicago, Chicago, Illinois
| | - Osman Ahmed
- Department of Interventional Radiology, University of Chicago, Chicago, Illinois.
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Lasanudin JEF, Laksono S, Kusharsamita H. Current Diagnosis and Management of Acute Pulmonary Embolism: A Strategy for General Practitioners in Emergency Department. ACTA MEDICA (HRADEC KRALOVE) 2023; 66:138-145. [PMID: 38588391 DOI: 10.14712/18059694.2024.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Pulmonary embolism (PE) is a disease with a relatively good prognosis when diagnosed and treated properly. This review aims to analyse available data and combine them into algorithms that physicians can use in the emergency department for quick decision-making in diagnosing and treating PE. The available data show that PE can be excluded through highly sensitive clinical decision rules, i.e. Pulmonary Embolism Rule-Out Criteria (PERC), Wells criteria, and Revised Geneva criteria, combined with D-dimer assessment. In cases where PE could not be excluded through the mentioned strategies, imaging modalities, such as compression ultrasonography (CUS), computed tomographic pulmonary angiography (CTPA), and planar ventilation/perfusion (V/Q) scan, are indicated for a definite diagnosis. Once a diagnosis has been made, treatment of PE depends on its mortality risk as patients are divided into low-, intermediate-, and high-risk cases. High-risk cases are treated for their hemodynamic instability, given parenteral or oral anticoagulant therapy, and are indicated for reperfusion therapy. Intermediate-risk PE is only given parenteral or oral anticoagulants and reperfusion is indicated when anticoagulants fail. Low-risk cases are given oral anticoagulants and based on the Hestia criteria, patients may be discharged and treated as outpatients.
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Affiliation(s)
| | - Sidhi Laksono
- Department of Cardiology and Vascular Medicine, Central Pertamina Hospital, Jakarta, Indonesia.
- Faculty of Medicine, Universitas Muhammadiyah Prof Dr Hamka, Tangerang, Indonesia.
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Chandra VM, Khaja MS, Kryger MC, Sista AK, Wilkins LR, Angle JF, Sharma AM. Mechanical aspiration thrombectomy for the treatment of pulmonary embolism: A systematic review and meta-analysis. Vasc Med 2022; 27:574-584. [PMID: 36373768 DOI: 10.1177/1358863x221124681] [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: 11/16/2022]
Abstract
INTRODUCTION There are no randomized trials studying the outcomes of mechanical aspiration thrombectomy (MAT) for management of pulmonary embolism (PE). METHODS We performed a systematic review and meta-analysis of existing literature to evaluate the safety and efficacy of MAT in the setting of PE. Inclusion criteria were as follows: studies reporting more than five patients, study involved MAT, and reported clinical outcomes and pulmonary artery pressures. Studies were excluded if they failed to separate thrombectomy data from catheter-directed thrombolysis data. Databases searched include PubMed, EMBASE, Web of Science until April, 2021. RESULTS Fourteen case series were identified, consisting of 516 total patients (mean age 58.4 ± 13.6 years). Three studies had only high-risk PE, two studies had only intermediate-risk PE, and the remaining nine studies had a combination of both high-risk and intermediate-risk PE. Six studies used the Inari FlowTriever device, five studies used the Indigo Aspiration system, and the remaining three studies used the Rotarex or Aspirex suction thrombectomy system. Four total studies employed thrombolytics in a patient-specific manner, with seven receiving local lysis and 17 receiving systemic lysis, and 40 receiving both. A random-effects meta-analyses of proportions of in-hospital mortality, major bleeding, technical success, and clinical success were calculated, which yielded estimate pooled percentages [95% CI] of 3.6% [0.7%, 7.9%], 0.5% [0.0%, 1.8%], 97.1% [94.8%, 98.4%], and 90.7% [85.5%, 94.3%]. CONCLUSION There is significant heterogeneity in clinical, physiologic, and angiographic data in the currently available data on MAT. RCTs with consistent parameters and outcomes measures are still needed.
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Affiliation(s)
- Vishnu M Chandra
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Minhaj S Khaja
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Marc C Kryger
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Akhilesh K Sista
- Department of Radiology, Division of Vascular & Interventional Radiology, NYU Langone Health, New York, NY, USA
| | - Luke R Wilkins
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - John F Angle
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Aditya M Sharma
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
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18
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Sun N, Chen Y, Liang X, Fan Y, Fang M, Gao X, Wang Y, Chen Y, Wang Z, Yu B, Tian J, Wu B. Clinical and hemodynamic features of acute pulmonary embolism patients diagnosed in cold weather predicts adverse clinical outcome. Front Cardiovasc Med 2022; 9:1055926. [DOI: 10.3389/fcvm.2022.1055926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022] Open
Abstract
BackgroundAcute pulmonary embolism (APE) is associated with peak incidence and mortality rate in winter. The present study sought to characterize the clinical and hemodynamic features of cold weather on APE patients.MethodsAll enrolled 224 APE patients underwent clinical and hemodynamic evaluation and baseline parameters were collected. Recruited patients were grouped by weather pattern on admission into cold and warm weather group. The correlation and prognostic values among cold weather and other variables were analyzed.ResultsCompared to warm weather group, patients in cold weather group present with more severe cardiac function, with adverse WHO-functional class (P = 0.032) and higher NT-proBNP concentration [1,853.0 (398.0, 5,237.0) pg/ml vs. 847.5 (56.8, 3,090.5) pg/ml, P = 0.001]. The cold weather group also displayed much critical hemodynamic status and heavier thrombosis load, with higher mPAP (29.1 ± 11.2mmHg vs. 25.6 ± 14.2mmHg, P = 0.045), higher PVR [3.3 (1.7, 6.0) wood units vs. 1.8 (0.9, 3.8) wood units, P < 0.001], higher Miller index (21.4 ± 5.9 vs. 19.1 ± 8.0, P = 0.024), and higher D-dimer levels [2,172.0 (854.5, 3,072.5) mg/L vs. 1,094.5 (210.5, 2,914.5) mg/L, P = 0.008]. Besides, cold weather showed well correlation with the above variables. Survival analysis showed APE patients in cold weather had significantly higher clinical worsening event rate (P = 0.010) and could be an independent predictor of adverse clinical outcome in the multivariate analysis (HR 2.629; 95% CI 1.127, 6.135; P = 0.025).ConclusionAPE patients in cold weather were associated with thrombus overload, cardiac dysfunction, hemodynamic collapse and higher clinical worsening event rate. Cold weather proves to be an independent predictor of adverse clinical outcome.
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Muacevic A, Adler JR. Outcomes of Surgical and Mechanical Thrombectomy in Massive Saddle Pulmonary Embolism: A National Perspective. Cureus 2022; 14:e29885. [PMID: 36348926 PMCID: PMC9629997 DOI: 10.7759/cureus.29885] [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] [Accepted: 09/25/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Saddle pulmonary embolism (PE) is a type of central PE that involves the bifurcation of the pulmonary arteries. First-line treatment is usually systemic thrombolytics, but surgical and mechanical thrombectomy (ST and MT) are used for patients with contraindications to thrombolytics or right heart strain. This study compares surgical and mechanical thrombectomy trends and outcomes in patients with saddle PE. Methods The data was extracted from the National In-Patient Sample (NIS) from 2016-2018 using the International Classification of Diseases-10-Clinical Modification (ICD-10-CM) diagnosis codes. We used the Cochrane-Armitage trend test to analyze the trends of ST and MT and the chi-square test for statistical analyses. A two-tailed p-value of <0.05 was considered statistically significant. Results The overall trend of MT in saddle PE rose from 2016 to 2018, while ST remained stable. Around 95% of patients undergoing ST/MT were emergent admissions, with 82.5% occurring in teaching hospitals. Patients of age >65 years and more with comorbidity burdens were more likely to undergo MT over ST. In-hospital mortality after ST was 15.1%, and after MT was 11.1% (p:<0.001). The most common complications after ST were congestive heart failure (CHF) and atrial fibrillation (AF), and after MT were vascular events and CHF. Conclusion The use of mechanical thrombectomy has steadily increased during the study period. ST is more common in large/teaching hospitals, weekend admissions, and patients transferred from other facilities. MT is more common in elderly patients with a higher comorbidity burden. Patients who underwent MT had lower mortality, length of hospital stay, and post-procedural complications.
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Robinson AE, Simpson NS, Hick JL, Moore JC, Jones GA, Fischer MD, Bravinder SZ, Kolbet KL, Reardon RF. Prehospital Ultrasound Diagnosis of Massive Pulmonary Embolism by Non-Physicians: A Case Series. PREHOSP EMERG CARE 2022; 27:826-831. [PMID: 35952352 DOI: 10.1080/10903127.2022.2113190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/06/2022] [Accepted: 07/27/2022] [Indexed: 10/15/2022]
Abstract
Massive pulmonary embolism (hemodynamically unstable, defined as systolic BP <90 mmHg) has significant morbidity and mortality. Point of care ultrasound (POCUS) has allowed clinicians to detect evidence of massive pulmonary embolism much earlier in the patient's clinical course, especially when patient instability precludes computerized tomography confirmation. POCUS detection of massive pulmonary embolism has traditionally been performed by physicians. This case series demonstrates four cases of massive pulmonary embolism diagnosed with POCUS performed by non-physician prehospital personnel.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota
| | - John L Hick
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota
- LifeLink III, Minneapolis, Minnesota
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Gregg A Jones
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota
| | - Michael D Fischer
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | | | | | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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Xu J, Zhou X, Liu Z, Xu Z. Spinal cord infarction secondary to pulmonary embolism-induced cardiac arrest: a case report. BMC Anesthesiol 2022; 22:275. [PMID: 36045349 PMCID: PMC9429726 DOI: 10.1186/s12871-022-01820-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Pulmonary embolism is a common cause of cardiac arrest. Pulmonary embolism-induced cardiac arrest typically suffers from ischemic injuries to various organs, including the central nervous system. However, spinal cord infarction is a rare complication of pulmonary embolism-induced cardiac arrest. At present, there is no case report on the occurrence of spinal cord infarction secondary to pulmonary embolism-induced cardiac arrest without accompanied cerebral complications. Case presentation A 72-year-old woman with dyspnea and chest tightness was admitted to the emergency room. Cardiac arrest occurred within a short period after admission. Subsequent computed tomographic pulmonary angiography revealed multiple pulmonary thromboses, which were highly suspected to be the cause of cardiac arrest. Thrombolytic therapy with alteplase was given after the return of spontaneous circulation. Unfortunately, she was found to be paraplegic in both lower extremities after regaining consciousness. Spinal cord infarction was confirmed by thoracic magnetic resonance imaging. Conclusions Despite receiving high-quality cardiopulmonary resuscitation, patients with cardiac arrest are at high risk of ischemic injury to the central nervous system. After the recovery of consciousness, clinicians should pay more attention to preclude the possibility of spinal cord infarction.
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22
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Tsarova K, Morgan AE, Melendres-Groves L, Ibrahim MM, Ma CL, Pan IZ, Hatton ND, Beck EM, Ferrel MN, Selzman CH, Ingram D, Alamri AK, Ratcliffe MB, Wilson BD, Ryan JJ. Imaging in Pulmonary Vascular Disease-Understanding Right Ventricle-Pulmonary Artery Coupling. Compr Physiol 2022; 12:3705-3730. [PMID: 35950653 DOI: 10.1002/cphy.c210017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The right ventricle (RV) and pulmonary arterial (PA) tree are inextricably linked, continually transferring energy back and forth in a process known as RV-PA coupling. Healthy organisms maintain this relationship in optimal balance by modulating RV contractility, pulmonary vascular resistance, and compliance to sustain RV-PA coupling through life's many physiologic challenges. Early in states of adaptation to cardiovascular disease-for example, in diastolic heart failure-RV-PA coupling is maintained via a multitude of cellular and mechanical transformations. However, with disease progression, these compensatory mechanisms fail and become maladaptive, leading to the often-fatal state of "uncoupling." Noninvasive imaging modalities, including echocardiography, magnetic resonance imaging, and computed tomography, allow us deeper insight into the state of coupling for an individual patient, providing for prognostication and potential intervention before uncoupling occurs. In this review, we discuss the physiologic foundations of RV-PA coupling, elaborate on the imaging techniques to qualify and quantify it, and correlate these fundamental principles with clinical scenarios in health and disease. © 2022 American Physiological Society. Compr Physiol 12: 1-26, 2022.
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Affiliation(s)
- Katsiaryna Tsarova
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ashley E Morgan
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Lana Melendres-Groves
- Division of Pulmonary and Critical Care Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Majd M Ibrahim
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Christy L Ma
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Irene Z Pan
- Department of Pharmacy, University of Utah Health, Salt Lake City, Utah, USA
| | - Nathan D Hatton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Emily M Beck
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Meganne N Ferrel
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah, USA
| | - Dominique Ingram
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Ayedh K Alamri
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | | | - Brent D Wilson
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John J Ryan
- Division of Cardiovascular Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
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Conde I, Katzen BT. Treatment of Pulmonary Embolism. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Abstract
The role of thrombolysis in submassive pulmonary embolism (PE) is controversial due to the high risk of hemorrhage. This study aimed to evaluate the role of half-dose tissue-type plasminogen activator (rt-PA) in preventing death/hemodynamic decompensation in submassive (intermediate-risk) PE without increasing the risk of bleeding. In a prospective, non-randomized, open-label, single-center trial, we compared 50 mg rt-PA plus low molecular weight heparin (LMWH) with LMWH in submassive (intermediate-risk) PE. Eligible cases had confirmed pulmonary hypertension on echocardiography, and/or right ventricular cavity expansion and/or interventricular septal deviation on echocardiography, and/or right to left ventricular ratio equal to or greater than 0.9 mm on CT angiography. The primary outcome was death or hemodynamic decompensation within 7 and 30 days after treatment was given. The primary safety outcome was major extracranial bleeding or hemorrhagic stroke within 7 days. Seventy-six patients were included in the study. Total death/hemodynamic decompensation in the first 7 and 30 days was significantly less in the half-dose rt-PA group than in the LMWH group (p=0.028 and p=0.009, respectively). No significant differences were found between the two groups in terms of recurrent embolism and pulmonary hypertension at 6-month follow-up (p=1.000 and p=0.778). There was no intracranial hemorrhage in any of the patients. There were no statistically significant differences between the two groups in terms of major or minor bleeding complications. This trial showed half-dose rt-PA treatment in submassive (intermediate-risk) PE prevented death/hemodynamic decompensation in the first 7-day and 30-day period compared with LMWH treatment without increasing the risk of bleeding.
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Affiliation(s)
- Emine Serap Yilmaz
- Pulmonary Medicine, Ordu University Faculty of Medicine, Training and Research Hospital, Ordu, Turkey
| | - Oğuz Uzun
- Pulmonary Medicine, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
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Hobohm L, Sagoschen I, Habertheuer A, Barco S, Valerio L, Wild J, Schmidt FP, Gori T, Münzel T, Konstantinides S, Keller K. Clinical use and outcome of extracorporeal membrane oxygenation in patients with pulmonary embolism. Resuscitation 2021; 170:285-292. [PMID: 34653550 DOI: 10.1016/j.resuscitation.2021.10.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 02/02/2023]
Abstract
AIM OF THE STUDY Extracorporeal membrane oxygenation (ECMO) is considered a life-saving treatment option for patients in cardiogenic shock or cardiac arrest undergoing cardiopulmonary resuscitation (CPR) due to acute pulmonary embolism (PE). We sought to analyze use and outcome of ECMO with or without adjunctive treatment strategies in patients with acute PE. METHODS We retrospectively analyzed data on patient characteristics, treatments, and in-hospital outcomes for all PE patients (ICD-code I26) undergoing ECMO in Germany between 2005 and 2018. RESULTS At total of 1,172,354 patients were hospitalized with PE; of those, 2,197 (0.2%) were treated with ECMO support. Cardiac arrest requiring cardiopulmonary resuscitation was present in 77,196 (6.5%) patients. While more than one fourth of those patients were treated with systemic thrombolysis alone (n = 20,839 patients; 27.0%), a minority of patients received thrombolysis and VA-ECMO (n = 165; 0.2%), embolectomy and VA-ECMO (n = 385; 0.5%) or VA-ECMOalone (n = 588; 0.8%). A multivariable logistic regression analysis indicated the lowest risk for in-hospital death in patients who received embolectomy in combination with VA-ECMO (OR, 0.50 [95% CI, 0.41-0.61], p < 0.001), thrombolysis and VA-ECMO (0.60 [0.43-0.85], p = 0.003) or VA-ECMO alone (0.68 [0.57-0.82], p < 0.001) compared to thrombolysis alone (1.04 [0.99-1.01], p = 0.116). CONCLUSION Our findings suggest that the use of VA-ECMO alone or as part of a multi-pronged reperfusion approach including embolectomy or thrombolysis might offer survival advantages compared to thrombolysis alone in patients with PE deteriorating to cardiac arrest.
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Affiliation(s)
- Lukas Hobohm
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany.
| | - Ingo Sagoschen
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Andreas Habertheuer
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Department of Angiology, University Hospital Zurich, Switzerland
| | - Luca Valerio
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany
| | - Johannes Wild
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Germany
| | | | - Karsten Keller
- Department of Cardiology, University Medical Center Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Germany; Medical Clinic VII, University Hospital Heidelberg, Germany
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Hassan AKM, Ahmed H, Ahmed Y, Elfadl AEA, Omar A. Efficacy and safety of hydro-mechanical defragmentation in intermediate- and high-risk pulmonary embolism. Egypt Heart J 2021; 73:84. [PMID: 34564780 PMCID: PMC8464550 DOI: 10.1186/s43044-021-00204-2] [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: 07/19/2021] [Accepted: 09/01/2021] [Indexed: 11/22/2022] Open
Abstract
Background Pulmonary embolism (PE) is the third most common acute cardiovascular syndrome. Percutaneous catheter directed hydro-mechanical defragmentation (HMD) is one of the recommended treatment options for PE in patients with contraindications to thrombolytic therapy or failed systemic thrombolysis (ST). We aimed to identify the safety and outcomes of catheter directed HMD in patients with high-risk PE. This nonrandomized controlled trial enrolled all patients with confirmed diagnoses of high- and intermediate-high-risk PE from October 2019 till January 2021. Fifty patients were included and divided into two groups by the PE response team according to the presence or absence of a contraindication for ST. Group B (ST) consists of 25 patients and group A (HMD) of 25 patients who cannot receive ST. Results The two groups were comparable regarding baseline clinical characteristics with mean age 51 ± 13 years. In group A, systolic blood pressure (BP) and oxygen saturation increased after 24 h (p = 0.002) and 48 h (p < 0.001) compared to pre-HMD procedure. Mean pulmonary artery systolic pressure (PASP) and respiratory rate (RR) decreased after 48 h and at 30 days (p < 0.001) compared to pre-HMD procedure. The increase in systolic BP and oxygen saturation were significantly higher in HMD group compared with ST group after 48 h and at 30 days (p < 0.007). The decrease in PASP and RR was significantly higher in HMD group compared to ST group after 48 h and at 30 days (p < 0.001). Mortality rate at 30 days was 20% in HMD group compared to 32% in ST group. Conclusions Catheter directed HMD for high-risk and intermediate-high-risk PE is safe and effective with acceptable mortality Trial registration Clinical trial ID: NCT04099186.
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Affiliation(s)
- Ayman K M Hassan
- Cardiology Department, Assiut University, P.Box: 71526, Asyut, Egypt.
| | - Heba Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | - Yousef Ahmed
- Chest Department, Assiut University, Asyut, Egypt
| | | | - Amany Omar
- Chest Department, Assiut University, Asyut, Egypt
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Bass GD, Zhao FS, Schweickert WD, Manaker S. A Retrospective Analysis of Malpractice-Related Procedure Rates for Internal Medicine Specialists at an Academic Medical Center. Jt Comm J Qual Patient Saf 2021; 47:704-710. [PMID: 34456152 DOI: 10.1016/j.jcjq.2021.08.001] [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: 03/29/2021] [Revised: 08/01/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Although malpractice litigation is common in the United States, the risk of a malpractice claim for procedures performed by internal medical practitioners is unknown. This study determined the frequency of malpractice claims related to procedures in a large department of medicine at an academic medical center over a five-year period. METHODS Researchers retrospectively reviewed all malpractice claims and procedures performed by internal medicine practitioners of all specialties between July 1, 2014, and June 30, 2019, in a department of medicine at a large academic medical center. A list of all procedures and Current Procedural Terminology codes performed by internal medicine practitioners was compiled. Active procedure-related malpractice claims and the total number of procedures performed during the study period were counted. RESULTS During the study period, 353,661 procedures were performed by internal medicine practitioners. During the same period, 76 active malpractice claims were identified, of which only 13 (17.1%) were procedure-related. For 2 different malpractice claims, a single patient had 2 procedures; thus 13 total claims related to the performance of 15 procedures. The proportion of procedure-related claims per total number of procedures performed was 0.37 claims/10,000 cases. The frequency of procedure-related malpractice claims per number of procedures performed ranged from 1 in 38 for pulmonary artery thrombolytic therapy to 1 in 137,325 for colonoscopy. CONCLUSION Procedure-related malpractice claims against internal medicine practitioners at a large academic medical center over a five-year period were infrequent despite significant procedural volume. Contextualizing procedure-related malpractice claims in terms of procedure-specific volume reframes the reporting of malpractice risk.
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Farzan N, Ghezelbash P, Hamidi F, Zeraatchi A. Pulmonary thromboembolism with transthoracic ultrasound and computed tomography angiography. THE CLINICAL RESPIRATORY JOURNAL 2021; 15:1337-1342. [PMID: 34402595 DOI: 10.1111/crj.13437] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 07/14/2021] [Accepted: 08/10/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The detection of pulmonary embolism in emergency department requires an urgent therapeutic and diagnostic attention. This study was performed to determine the accuracy and efficacy of ultrasound in the diagnosis of pulmonary embolism. METHODS In this study, 110 patients who referred to the emergency department with traumatic embolism symptoms were enrolled. All the patients underwent computed tomography (CT) angiography. Patients were divided into positive and negative outcomes according to the results of transthoracic ultrasonography and CT angiography. RESULTS In this study, 110 patients were enrolled, of whom 52 (47.3%) were male and 58 (52.7%) were female. Among the patients, 100 (90.9%) patients presented with dyspnea, whereas the frequency of pleural pain was 27% (24.5%). Sensitivity, specificity, positive predictive value, and negative predictive value for ultrasound were 45.67%, 77.41%, 88.09%, and 35.29%, respectively. The positive outcomes from CT scan were significantly associated with gender, p = 0.005. The gender and transthoracic ultrasonography outcomes were also significantly correlated, p = 0.019, and the outcomes of ultrasound were significantly different from those of CT scan, p = 0.008. CONCLUSION Transthoracic ultrasonography may be used to diagnose pulmonary embolism as a technique in the emergency department, especially in patients who are unable to move due to the severity of the disease. However, further comparative studies are required in this aspect.
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Affiliation(s)
- Nina Farzan
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti Hospital, Qom University of Medical Sciences, Qom, Iran
| | - Parviz Ghezelbash
- Department of Radiology, School of Medicine, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Fatemeh Hamidi
- Department of Emergency Medicine, School of Medicine, Valiasr-e-Asr Hospital, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Alireza Zeraatchi
- Department of Emergency Medicine, School of Medicine, Valiasr-e-Asr Hospital, Ayatollah Mousavi Hospital, Zanjan University of Medical Sciences, Zanjan, Iran
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29
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Singh V, Muthusamy N, Ikwuazom CP, Sicat CS, Schwarzkopf R, Rozell JC. Postoperative venous thromboembolism event increases risk of readmissions and reoperation following total joint arthroplasty: a propensity-matched cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1055-1061. [PMID: 34258642 DOI: 10.1007/s00590-021-03071-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE The clinical impact of postoperative venous thromboembolism (VTE) following total joint arthroplasty (TJA) remains unclear. In this study, we evaluate the effect of VTE following TJA on postoperative outcomes including discharge disposition, readmission rates, and revision rates. METHODS We retrospectively reviewed all patients over the age of 18 who underwent primary, elective THA or TKA between 2013 and 2020. Patients were stratified into two cohorts based on whether or not they had a VTE following their procedure. Baseline patient demographics and clinical outcomes such as readmissions and revisions were collected. Propensity score matching was performed to limit significant demographic differences, while independent sample t-tests and Pearson's chi-squared test were used to compare outcomes of interest between the groups. RESULTS After propensity score matching, there were 109 patients in each cohort, representing a total of 218 patients for the matched comparison. Prior to matching, the VTE cohort was noted to have a significantly higher BMI than the non-VTE cohort (32.22 ± 6.27 vs 30.93 ± 32.04 kg/m2, p = 0.032). All other patient demographics were similar. Compared to the non-VTE cohort, the VTE cohort was less likely to be discharged home (66.1% vs 80.7%; p = 0.021), had a higher rate of 90-day all-cause readmissions (27.5% vs 9.2%, p = 0.001), and a higher two-year revision rate (11.0% vs 0.9%, p = 0.003). CONCLUSION Patients with postoperative VTE were less likely to be discharged home and had higher 90-day readmission and two-year revision rates. Therefore, mitigating perioperative risk factors, initiating appropriate long-term anticoagulation, and maintaining close follow-up for patients with postoperative VTE may play significant roles in decreasing hospital costs and the economic burden to the healthcare system. LEVEL OF EVIDENCE III Retrospective Cohort Study.
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Affiliation(s)
- Vivek Singh
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Nishanth Muthusamy
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Chibuokem P Ikwuazom
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA.,Department of Orthopaedic Surgery and Rehabilitation Medicine, SUNY Downstate Health Science Center, New York, NY, USA
| | - Chelsea Sue Sicat
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopaedic Surgery, Division of Adult Reconstruction, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA.
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Hobohm L, Schmidt FP, Gori T, Schmidtmann I, Barco S, Münzel T, Lankeit M, Konstantinides SV, Keller K. In-hospital outcomes of catheter-directed thrombolysis in patients with pulmonary embolism. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:258-264. [PMID: 33620441 DOI: 10.1093/ehjacc/zuaa026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/16/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022]
Abstract
AIMS Catheter-directed treatment of acute pulmonary embolism (PE) is technically advancing. Recent guidelines acknowledge this treatment option for patients with overt or imminent haemodynamic decompensation, particularly when systemic thrombolysis is contraindicated. We investigated patients with PE who underwent catheter-directed thrombolysis (CDT) in the German nationwide inpatient cohort. METHODS AND RESULTS Data from hospitalizations with PE (International Classification of Disease code I26) between 2005 and 2016 were collected by the Federal Office of Statistics in Germany. Patients with PE who underwent CDT (OPS 8-838.60 or OPS code 8-83b.j) were compared with patients receiving systemic thrombolysis (OPS code 8-020.8), and those without thrombolytic or other reperfusion treatment. The analysis was not prespecified; therefore, our findings can only be considered to be hypothesis generating. We analysed data from 978 094 hospitalized patients with PE. Of these, 41 903 (4.3%) patients received thrombolytic treatment [systemic thrombolysis in 4.2%, CDT in 0.1% (1175 patients)]. Among patients with shock, CDT was associated with lower in-hospital mortality compared to systemic thrombolysis [odds ratios (OR) 0.30 (95% 0.14-0.67); P = 0.003]. Intracranial bleeding occurred in 14 (1.2%) patients who received CDT. Among haemodynamically stable patients with right ventricular dysfunction (intermediate-risk PE), CDT also was associated with a lower risk of in-hospital mortality compared to systemic thrombolysis {OR 0.55 [95% confidence interval (CI) 0.40-0.75]; P < 0.001} or no thrombolytic treatment [0.45 (95% CI 0.33-0.62); P < 0.001]. CONCLUSION In the German nationwide inpatient cohort, based on administrative data, CDT was associated with lower in-hospital mortality rates compared to systemic thrombolysis, but the overall rate of intracranial bleeding in patients who received CDT was not negligible. Prospective controlled data are urgently needed to determine the true value of this treatment option in acute PE.
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Affiliation(s)
- Lukas Hobohm
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Frank P Schmidt
- Department of Cardiology, Mutterhaus Trier, Feldstraße 16, 54290 Trier, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Johannes Gutenberg University Mainz, Obere Zahlbacherstraße 69, 55131 Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Clinic of Angiology, University Hospital Zurich, Rämistraße 100, 8091 Zurich, Switzerland
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Mareike Lankeit
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Klinikum (CVK), Charité - University Medicine, Augustenburgerplatz 1, 13353 Berlin, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Karsten Keller
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg University Mainz), Langenbeckstrasse 1, 55131 Mainz, Germany.,Department of Cardiology, University Medical Center Mainz (Johannes Gutenberg University Mainz), DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131 Mainz, Germany.,Medical Clinic VII, Department of Sports Medicine, University Hospital Heidelberg, Dragana, 68100 8: Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
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Sertic F, Diagne D, Chavez L, Richards T, Berg A, Acker M, Giri JS, Szeto WY, Khandhar S, Gutsche J, Pugliese S, Fiorilli P, Rame E, Bermudez C. Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism. Eur J Cardiothorac Surg 2020; 58:923-931. [PMID: 32725134 DOI: 10.1093/ejcts/ezaa189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.
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Affiliation(s)
- Federico Sertic
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dieynaba Diagne
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lexy Chavez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Richards
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Berg
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Acker
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay S Giri
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sameer Khandhar
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Gutsche
- Department of Intensive Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Pugliese
- Department of Medicine, Division of Pulmonology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Fiorilli
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eduardo Rame
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Lu SY, Dalia AA, Lang M, Fitzsimons MG. Perioperative Outcomes of Thrombectomy Patients Using Venovenous Bypass and Suction Filtration With General Anesthesia. J Cardiothorac Vasc Anesth 2020; 35:1040-1045. [PMID: 33051147 DOI: 10.1053/j.jvca.2020.09.104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/23/2020] [Accepted: 09/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE AngioVac (Angiodynamics, Latham, NY) is a novel drainage system that offers a less-invasive approach compared with open surgical thromboembolectomy to remove intracardiac and intravascular thrombotic and embolic material. For this study, the authors' single-center experience with patients undergoing thromboembolectomy using the AngioVac system was reviewed retrospectively to evaluate anesthetic management and postoperative complications. DESIGN Retrospective, observational study. SETTING Single institution, quaternary care hospital. PARTICIPANTS The study comprised 20 consecutive patients whose treatment included the AngioVac between January 2016 and November 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Twenty patients underwent AngioVac suction filtration. The mean age was 56 years, and women comprised 35% of the patient cohort. Indications for AngioVac suction filtration included deep venous thrombosis involving the inferior vena cava (n = 12 [60%]), right atrial mass/thrombus (n = 11 [55%]), right ventricular mass/thrombus (n = 3 [15%]), and pulmonary embolism(n = 2 [10%]). All patients required vasopressor support, and nine patients (45%) required blood transfusion during the procedure. There was no intraoperative death or cardiac arrest associated with the procedure. The 30-day mortality was zero, and in-hospital mortality was 5% (1/20). Significant postoperative complications occurred in 11/20 patients (55%). Postoperative left ventricular dysfunction (36% v 0%; p < 0.05), preoperative shock requiring vasopressors (36% v 0%; p < 0.05), postoperative blood transfusion (100% v 56%; p < 0.05), and having undergone recent surgery (64% v 11%; p < 0.05) were associated with increased odds of experiencing postoperative complications. CONCLUSIONS The rate of intraoperative complication during AngioVac suction filtration is low, but vasopressors and blood transfusions often are required. Patients at increased risk of developing postoperative complications potentially can be identified as having undergone recent surgery, experiencing preoperative shock requiring vasopressors or postoperative left ventricular dysfunction, and requiring postoperative blood transfusion.
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Affiliation(s)
- Shu Y Lu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Maximilian Lang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Michael G Fitzsimons
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Gupta R. Reappraising Thrombolytic Therapy and Risk Stratification for Acute Pulmonary Embolism: Where Does Hypoxemia Fit In? Am J Med Sci 2020; 360:107-108. [DOI: 10.1016/j.amjms.2020.04.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 04/23/2020] [Indexed: 11/26/2022]
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Tomkiewicz EM, Kline JA. Concise Review of the Clinical Approach to the Exclusion and Diagnosis of Pulmonary Embolism in 2020. J Emerg Nurs 2020; 46:527-538. [PMID: 32317119 DOI: 10.1016/j.jen.2020.02.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 02/28/2020] [Indexed: 01/08/2023]
Abstract
Pulmonary embolism has extremely varied clinical presentations and can be difficult to diagnose. Clinical decision rules can help determine the probability of pulmonary embolism by assessment of the clinical presentation. After the diagnosis, several prognostic rules can be used to risk-stratify and facilitate outpatient treatment of pulmonary embolism. This review addresses the utility of clinical decision rules, biomarkers in the diagnosis of pulmonary emoblism, high-risk patient phenotypes, the use of this data to make disposition decisions for patients with a diagnosis of PE, and recent shifts in the management of pulmonary embolism in the clinical setting.
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Percutaneous mechanical thrombectomy in patients with high-risk pulmonary embolism and contraindications for thrombolytic therapy. Radiol Oncol 2020; 54:62-67. [PMID: 32061168 PMCID: PMC7087421 DOI: 10.2478/raon-2020-0006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 01/23/2020] [Indexed: 11/21/2022] Open
Abstract
Background High-risk pulmonary embolism is associated with a high early mortality rate. We report our experience with percutaneous mechanical thrombectomy in patients with high-risk pulmonary embolism and contraindications for thrombolytic therapy. Patients and methods This was a retrospective analysis of consecutive patients with high-risk pulmonary embolism and contraindications to thrombolytic therapy. They were treated with percutaneous mechanical thrombectomy which included thrombectomy and additional thrombus aspiration when needed. Clinical parameters and survival to discharge were measured. Results From November 2005 to September 2015 we treated 25 patients with a mean age of 62.6 ± 12.7 years, 64% were men. Mean simplified Pulmonary Embolism Severity Index was 2.9. Mean maximum lactate levels were 7.8 ± 6.6 mmol/L, vasopressors were used in 77%, and 59% needed mechanical ventilation. Mechanical treatment included thrombus fragmentation complemented with aspiration (56%) and aspiration using Aspirex®S catheter (44%). Local (5 patients; 20%) and systemic (3 patients; 12%) thrombolytics were used as a salvage therapy. We observed nonsignificant improvements in systemic blood pressure (100 ± 41 mm Hg vs 119 ± 34; p = 0.100) and heart frequency (99 ± 35 min-1 vs 87 ± 31 min-1; p = 0.326) before and after treatment, respectively. Peak systolic tricuspid pressure gradient was significantly lower after treatment (57 ± 14 mm Hg vs 31 ± 3 mm Hg; p = 0.018). Overall the procedure was technically successful in 20 patients (80%) and 17 patients (68%) survived to hospital discharge. Conclusions In patients with high-risk pulmonary embolism who cannot receive thrombolytic therapy, percutaneous mechanical thrombectomy is a promising alternative to reduce pulmonary artery pressure.
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Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism as Bridge to Therapy. ASAIO J 2020; 66:146-152. [DOI: 10.1097/mat.0000000000000953] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Hashimoto T, Ando M, Kan T, Fujishima N, Yamasue M, Komiya K, Umeki K, Nureki SI, Kadota JI. Asthma Exacerbation Coincident with Saddle Pulmonary Embolism and Paradoxical Embolism. TOHOKU J EXP MED 2019; 248:137-141. [PMID: 31243182 DOI: 10.1620/tjem.248.137] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Saddle pulmonary embolism (PE) and paradoxical embolism (PDE) are life-threatening disorders carrying a risk of sudden death, and their prompt diagnosis is extremely important. Saddle PE is a radiologic definition and refers to a thrombus that straddles the bifurcation of the pulmonary artery trunk, carrying a risk of sudden hemodynamic collapse. PDE is defined as a systemic arterial embolus due to the passage of a venous thrombus though a right-to-left shunt, such as patent foramen ovale (PFO). We herein present the rare case of asthma exacerbation coincident with saddle PE and PDE. A 69-year-old woman with asthma was suffering from dyspnea, pulse attenuation of the left radial artery and left upper limb pain. An arterial blood gas analysis revealed hypoxemia, and a pulmonary function test demonstrated an obstructive pattern. Enhanced computed tomography (CT) revealed saddle PE, right popliteal venous thrombosis, and left brachial artery occlusion. After the treatment with edoxaban, an anticoagulant, and aspirin, the PE was significantly alleviated, and the brachial artery occlusion was recanalized. Subsequently, the right-to-left shunt through PFO was confirmed, and PDE was suspected of inducting her brachial artery embolism. In the present case, the pulse attenuation of the radial artery and upper limb pain prompted us to consider peripheral vascular disease or coagulation disorders. Physicians should keep in mind that patients with asthma are at considerable risk of PE, and it is important to be aware of possible PFO in patients presenting with the coexistence of PE and systemic arterial embolism.
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Affiliation(s)
- Takehiro Hashimoto
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Masaru Ando
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Takamasa Kan
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Nobuhiro Fujishima
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Mari Yamasue
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Kosaku Komiya
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Kenji Umeki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Shin-Ichi Nureki
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
| | - Jun-Ichi Kadota
- Department of Respiratory Medicine and Infectious Diseases, Oita University Faculty of Medicine
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The Incidence and Outcomes of Surgical Pulmonary Embolectomy in North America. Ann Thorac Surg 2019; 107:1401-1408. [DOI: 10.1016/j.athoracsur.2018.10.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 09/03/2018] [Accepted: 10/10/2018] [Indexed: 11/19/2022]
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Abstract
Intermediate-risk pulmonary embolism is common and carries a risk of progression to hemodynamic collapse and death. Catheter-directed thrombolysis is an increasingly used treatment option, based largely on the assumptions that it is more efficacious than anticoagulation alone and safer than systemic thrombolysis. In this review, we critically analyze the published data regarding catheter-directed thrombolysis for the treatment of intermediate-risk pulmonary embolism. Catheter-directed thrombolysis reduces right heart strain and lowers pulmonary artery pressures more quickly than anticoagulation alone. The mortality for patients with intermediate-risk pulmonary embolism treated with catheter-directed thrombolysis is low, between 0% and 4%. However, similarly low mortality is seen with anticoagulation alone. Catheter-directed thrombolysis appears to be safer than systemic thrombolysis, and procedural complications are uncommon. Bleeding risk appears to be slightly higher than with anticoagulation alone. Randomized, controlled trials are needed to compare the efficacy and safety of catheter-directed thrombolysis versus anticoagulation for intermediate-risk pulmonary embolism. There is no evidence that catheter-directed thrombolysis decreases the incidence of chronic thromboembolic pulmonary hypertension. There is no evidence from clinical studies that ultrasound-assisted thrombolysis is more effective or safer than standard catheter-directed thrombolysis.
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Kim MS, Lee JH, Cho HJ, Cho JY, Choi JO, Hwang KK, Yoo BS, Kang SM, Choi DJ. KSHF Guidelines for the Management of Acute Heart Failure: Part III. Specific Management of Acute Heart Failure According to the Etiology and Co-morbidity. Korean Circ J 2019; 49:46-68. [PMID: 30637995 PMCID: PMC6331326 DOI: 10.4070/kcj.2018.0351] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 12/31/2022] Open
Abstract
The prevalence of heart failure (HF) is on the rise due to the aging of society. Furthermore, the continuous progress and widespread adoption of screening and diagnostic strategies have led to an increase in the detection rate of HF, effectively increasing the number of patients requiring monitoring and treatment. Because HF is associated with substantial rates of mortality and morbidity, as well as high socioeconomic burden, there is an increasing need for developing specific guidelines for HF management. The Korean guidelines for the diagnosis and management of chronic heart failure (CHF) were introduced in March 2016. However, CHF and acute heart failure (AHF) represent distinct disease entities. Here, we introduce the Korean guidelines for the management of AHF with reduced or preserved ejection fraction. Part III of this guideline covers management strategies optimized according to the etiology of AHF and the presence of co-morbidities.
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Affiliation(s)
- Min Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hyun Jai Cho
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Jin Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Kuk Hwang
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Seok Min Kang
- Division of Cardiology, Department of Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Lee SN, Yoo KD, Jo MS. Successful Endovascular Management of Common Femoral Artery Perforation During Cannulation for Extracorporeal Membrane Oxygenation. Int Heart J 2018; 60:231-234. [PMID: 30393266 DOI: 10.1536/ihj.18-266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In massive pulmonary thromboembolism, requiring cardiopulmonary resuscitation, venous-arterial extracorporeal membrane oxygenation can decompress the overloaded right atrium and ventricle while stabilizing hemodynamic status. However, vascular injuries occur in slightly less than 20% of cases during cannulation. In a 44-year-old woman with suspected pulmonary thromboembolism, a common femoral artery perforation occurred unexpectedly during cannulation for extracorporeal membrane oxygenation. The patient was unstable due to active bleeding. Fortunately, we occluded the bleeding site using a stent. Interventional cardiologists are frequently challenged by vascular injury during cannulation for extracorporeal membrane oxygenation. We recommend imaging modalities to prevent vascular complications. However, if vascular injuries occur, stent placement should be considered for patients with arterial perforation during cannulation for extracorporeal membrane oxygenation.
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Affiliation(s)
- Su Nam Lee
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea
| | - Ki-Dong Yoo
- Department of Internal Medicine, St. Vincent's Hospital, The Catholic University of Korea
| | - Min Seop Jo
- Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, The Catholic University of Korea
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Abstract
PURPOSE OF REVIEW Acute pulmonary embolism is a major cause of morbidity and mortality in the USA and throughout the world. This review will summarize recent developments in short- and long-term mortality risk assessment after an acute pulmonary embolism. RECENT FINDINGS Recent guidelines have emphasized risk stratification of acute PE patients on the basis of blood pressure, right ventricular size, and biomarker status. Ongoing work is testing various acute treatment strategies for improvement of symptom burden, length of stay, quality of life, and possibly mortality risk reduction. Long-term outcomes among subjects with acute PE are less well studied. Long-term mortality largely correlates with baseline co-morbidity burden, although there may be an association between acute PE severity and long-term outcomes. Acute PE risk stratification and treatment, as well as long-term follow-up of patients with acute PE, are rapidly developing areas and many promising innovations are underway.
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Alirezaei T, Hajimoradi B, Pishgahi M, Nekooghadam SM, Golmohamadi M. Successful systemic thrombolytic therapy for massive pulmonary embolism in a patient with breast cancer, brain metastasis, and thrombocytopenia: A case report. Clin Case Rep 2018; 6:1431-1435. [PMID: 30147877 PMCID: PMC6099001 DOI: 10.1002/ccr3.1629] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 04/26/2018] [Accepted: 05/08/2018] [Indexed: 11/11/2022] Open
Abstract
A female with massive PTE and absolute contraindication for thrombolytic did not meet guidelines due to unavailability of catheter or surgical embolectomy and giving thrombolytic as a last resort to save a life. In such cases, physicians should consider to act outside of the guidelines to save a life.
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Affiliation(s)
- Toktam Alirezaei
- Cardiology Department of Shohaday‐e‐Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Behzad Hajimoradi
- Cardiology Department of Shohaday‐e‐Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mehdi Pishgahi
- Cardiology Department of Shohaday‐e‐Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Seyyed Mojtaba Nekooghadam
- Internal Department of Shohaday‐e‐Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
| | - Mohamad Golmohamadi
- Internal Department of Shohaday‐e‐Tajrish HospitalShahid Beheshti University of Medical SciencesTehranIran
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Friedman T, Winokur RS, Quencer KB, Madoff DC. Patient Assessment: Clinical Presentation, Imaging Diagnosis, Risk Stratification, and the Role of Pulmonary Embolism Response Team. Semin Intervent Radiol 2018; 35:116-121. [PMID: 29872247 DOI: 10.1055/s-0038-1642040] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Pulmonary embolism (PE) is currently the third leading cause of death and moreover is likely underdiagnosed. PE remains the most common preventable cause of hospital deaths in the United States, which may be attributable to its diagnostic challenges. Although difficult to diagnose, patient mortality rates are time-dependent, and thus, the suspicion and diagnosis of PE in a timely manner is imperative. Diagnosis based on several criteria which may dictate imaging workup as well as laboratory tests and clinical parameters are discussed. The evolution of treatment guidelines via various clinical trials and recommendations is outlined, setting the stage for the use of fibrinolytics, whether systemic or catheter directed. Treatment, including fibrinolytics, is predicated on patient triage into three large categories-massive, submassive, or low-risk PE. Additionally, a relatively new concept of a multidisciplinary team composed of several subspecialty experts known as the PE response team (PERT) is discussed. PERT's timely and unified recommendations have been shown to optimize care and decrease mortality while tailoring treatment to each individual afflicted by PE.
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Affiliation(s)
- Tamir Friedman
- Section of Interventional Radiology, Department of Radiology, Advanced Medical Imaging, Torrington, Connecticut
| | - Ronald S Winokur
- Section of Interventional Radiology, Department of Radiology, Weill Cornell/New York Presbyterian Hospital, New York, New York
| | - Keith B Quencer
- Section of Interventional Radiology, Department of Radiology, University of Utah, Salt Lake City, Utah
| | - David C Madoff
- Section of Interventional Radiology, Department of Radiology, Weill Cornell/New York Presbyterian Hospital, New York, New York
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Extracorporeal Life Support as Salvage Therapy for Massive Pulmonary Embolus and Cardiac Arrest in Pregnancy. J Emerg Med 2018; 55:121-124. [PMID: 29739630 DOI: 10.1016/j.jemermed.2018.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 02/26/2018] [Accepted: 04/10/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Massive pulmonary embolus (PE) with prolonged cardiac arrest in the setting of pregnancy has few treatment options. Selections are further restricted if there are contraindications to the standard therapies of embolectomy and thrombolysis. We report a case of extracorporeal life support (ECLS) used as salvage therapy for a critically ill pregnant patient. CASE REPORT A 21-year-old woman presented to a small rural hospital with chest pain, dyspnea, hypoxia, and syncope. In their emergency department, she suffered 2 episodes of cardiac arrest requiring cardiopulmonary resuscitation, and fetal demise followed. A computed tomography scan revealed a saddle PE. She was transferred to our tertiary care hospital and arrived critically ill, on multiple vasopressors, and in cardiogenic shock. Because standard treatments, namely thrombolysis and embolectomy, were contraindicated in this case, ECLS was employed for 7 days. She was discharged home after 23 days, and at follow-up 5 months after her admission, she was found to have made a near-complete recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ECLS is a viable option as salvage therapy for pregnant patients with massive PE who have contraindications to thrombolysis and embolectomy.
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Lampert J, Bikdeli B, Green P, Baldwin MR. Systemic thrombolysis in a patient with massive pulmonary embolism and recent glioblastoma multiforme resection. BMJ Case Rep 2017; 2017:bcr-2017-221578. [PMID: 29191822 DOI: 10.1136/bcr-2017-221578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
While trials of systemic thrombolysis for submassive and massive pulmonary embolism (PE) report intracranial haemorrhage (ICH) rates of 2%-3%, the risk of ICH in patients with recent brain surgery or intracranial neoplasm is unknown since these patients were excluded from these trials. We report a case of massive PE treated with systemic thrombolysis in a patient with recent neurosurgery for an intracranial neoplasm. We discuss the risks and benefits of systemic thrombolysis for massive PE in the context of previous case reports, prior cohort studies and trials, and current guidelines. There may be times when the immediate risk of death from massive PE outweighs the risk of ICH from systemic thrombolysis, even when guideline-listed major contraindications exist. This case provides an example of how the haemodynamic benefit of systemic thrombolysis outweighed the impact of ICH in a patient who had undergone recent neurosurgical resection of a glioblastoma multiforme tumour.
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Affiliation(s)
- Joshua Lampert
- Department of Internal Medicine, Columbia University Medical Center, New York City, New York, USA
| | - Behnood Bikdeli
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Philip Green
- Division of Cardiology, Columbia University Medical Center, New York, NY
| | - Matthew R Baldwin
- Division of Pulmonary and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY
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Alkinj B, Pannu BS, Apala DR, Kotecha A, Kashyap R, Iyer VN. Saddle vs Nonsaddle Pulmonary Embolism: Clinical Presentation, Hemodynamics, Management, and Outcomes. Mayo Clin Proc 2017; 92:1511-1518. [PMID: 28890217 DOI: 10.1016/j.mayocp.2017.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 06/25/2017] [Accepted: 07/18/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To understand the clinical significance, hemodynamic presentation, management, and outcomes of patients presenting with saddle pulmonary embolism (PE). METHODS All patients with saddle PE diagnosed at Mayo Clinic in Rochester, Minnesota, from January 1, 1999, through December 31, 2014, were included in this study. These patients were age and simplified Pulmonary Embolism Severity Index (sPESI) matched (1:1) to a nonsaddle PE cohort. Both groups were then classified into massive, submassive, and low-risk PE based on established criteria and compared for clinical presentation, management, and outcomes. RESULTS A total of 187 consecutive patients with saddle PE were identified. The saddle PE group presented more frequently with massive PE (31% vs 20%) and submassive PE (49% vs 32%), whereas low-risk PE was more common in the nonsaddle PE group (48% vs 20%). Systemic thrombolysis was used more frequently in the saddle PE group on admission (10% vs 4%; P=.04) and later during hospitalization (3.2% vs 0%; P=.03). Late major adverse events were similar in both groups except for mechanical ventilation (6% in saddle PE vs 1% in nonsaddle PE; P=.02). Overall in-hospital mortality did not differ between the 2 groups (4.3% in saddle PE vs 5.4% in nonsaddle PE; P=.81). CONCLUSION Although patients with saddle PE presented with higher rates of hemodynamic compromise and need for thrombolysis and mechanical ventilation, we found no difference in short-term outcomes compared with an age- and severity-matched nonsaddle PE cohort. Overall, in-hospital mortality was low in both groups.
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Affiliation(s)
- Bashar Alkinj
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Bibek S Pannu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Dinesh R Apala
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Aditya Kotecha
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rahul Kashyap
- Department of Anesthesia and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Vivek N Iyer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.
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Park SJ, Kwon CH, Bae BJ, Kim BS, Kim SH, Kim HJ, Hwang HK, Chung SM. Diagnostic value of the corrected QT difference between leads V1 and V6 in patients with acute pulmonary thromboembolism. Medicine (Baltimore) 2017; 96:e8430. [PMID: 29069044 PMCID: PMC5671877 DOI: 10.1097/md.0000000000008430] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
In acute pulmonary thromboembolism (PTE), right ventricular pressure overload impairs right-sided cardiac conduction and repolarization. We hypothesized that if heterogeneity of repolarization between right and left ventricles occurs in acute PTE, there would be the difference of repolarization between them. Therefore, we aimed to evaluate the diagnostic value of corrected QT interval (QTc) difference between leads V1 and V6 (V1 - V6) in patients with acute PTE.A total of 89 patients with suspected acute PTE who underwent computed tomographic angiography (CTA) were enrolled from January to December 2015. PTE was identified by CTA. We compared electrocardiographic (ECG) parameters, especially QTc difference (V1 - V6) between patients with PTE and those without PTE.Acute PTE was finally diagnosed in 45 patients. Clinical situations including the chief complaint were not different between PTE and non-PTE groups. S1Q3T3, a traditional ECG marker, had no diagnostic value for acute PTE. Patients with PTE had a significantly longer mean QTc in V1 (454.6 ± 44.3 vs 417.5 ± 31.3 ms, P < .001) and larger QTc difference (V1 - V6) (34.8 ± 30.5 vs -12.5 ± 16.6 ms, P < .001) than non-PTE controls. QTc difference (V1 - V6) was negative in all patients without PTE. PTE patients had a higher prevalence of T wave inversion in leads III (51.1% vs 29.5%, P = .038) and V1 (82.2% vs 38.6%, P < .001). A QTc difference (V1 - V6) of ≥20 ms identified PTE with 82.2% sensitivity, 100.0% specificity, and 100.0% positive predictive value.QTc difference (V1 - V6) had an excellent diagnostic value for differentiating patients with and without acute PTE.
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Abstract
Venous thromboembolism is the formation of a blood clot in the vein. It mainly consists of 2 life-threatening conditions-deep venous thrombosis and pulmonary embolism. Deep venous thrombosis is a potentially dangerous condition with grave sequelae, the worst of which is pulmonary embolism. Venous thromboembolism can also lead to multiple other conditions with significant morbidity and mortality that include extension of thrombi, pulmonary hypertension, recurrence, and postthrombotic syndrome. An update on the epidemiology, etiology, and pathogenesis of venous thromboembolism will be reviewed in this article.
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50
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Abstract
Venous thromboembolism (VTE) has a wide range of clinical presentations. Deep venous thrombosis may occur in upper or lower extremities or in visceral veins. Extremity deep venous thrombosis usually manifests with unilateral painful swelling in the limb, while visceral deep venous thrombosis manifestations vary on the basis of the involved organ. Pulmonary embolism classically manifests with sudden pleuritic chest pain and unexplained dyspnea. Superficial thrombophlebitis usually presents with acute inflammation around a palpable thrombosed superficial vein. Risk factors of VTE are either inherited or acquired. The inherited causes of VTE tend to be familial and more common in younger patients. The common acquired risk factors of VTE include previous history of venous thrombosis, immobilization, recent surgery or trauma, malignancy, and pregnancy. Identifying high-risk patients for VTE based on these risk factors is the cornerstone to provide the prophylactic treatment to prevent thrombotic events.
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