The role of thrombolytic therapy in pulmonary embolism

Ultrasound Trigger Ce-Based MOF Nanoenzyme For Efficient Thrombolytic Therapy

The inflammatory damage caused by thrombus formation and dissolution can increase the risk of thrombotic complications on top of cell death and organ dysfunction caused by thrombus itself. Therefore, a rapid and precise thrombolytic therapy strategy is in urgent need to effectively dissolve thrombus and resist oxidation simultaneously. In this study, Ce-UiO-66, a cerium-based metal-organic framework (Ce-MOF) with reactive oxygen species (ROS) scavenging properties, encapsulated by low-immunogenic mesenchymal stem cell membrane with inflammation-targeting properties, is used to construct a targeted nanomedicine Ce-UiO-CM. Ce-UiO-CM is applied in combination with external ultrasound stimulation for thrombolytic therapy in rat femoral artery. Ce-UiO-66 has abundant Ce (III)/Ce (IV) coupling sites that react with hydrogen peroxide (H2O2) to produce oxygen, exhibiting catalase (CAT) activity. The multi-cavity structure of Ce-UiO-66 can generate electron holes, and its pore channels can act as micro-reactors to further enhance its ROS scavenging capacity. Additionally, the porous structure of Ce-UiO-66 and the oxygen produced by its reaction with H2O2 may enhance the cavitation effects of ultrasound, thereby improving thrombolysis efficacy.

The genetic associations of COVID-19 on genitourinary symptoms

Background

Recently emerged reports indicated that patients with coronavirus disease 2019 (COVID-19) might experience novo genitourinary symptoms after discharge. Nevertheless, the causal associations and underlying mechanisms remain largely unclear.

Methods

Genome-wide association study (GWAS) statistics for COVID-19 and 28 genitourinary symptoms with consistent definitions were collected from the COVID-19 Host Genetic Initiative, FinnGen, and UK Biobanks. Mendelian randomization (MR) analyses were applied to explore the causal effects of COVID-19 on genitourinary symptoms by selecting single-nucleotide polymorphisms as instrumental variables. Meta-analyses were conducted to evaluate the combined causal effect. Molecular pathways connecting COVID-19 and its associated disorders were evaluated by weighted gene co-expression network analysis (WGCNA) and enrichment analyses to extract insights into the potential mechanisms underlying the connection.

Results

The MR and meta-analyses indicated that COVID-19 was causally associated with increased risk for calculus of the lower urinary tract (LUTC, OR: 1.2984 per doubling in odds of COVID-19, 95% CI: 1.0752-1.5680, p = 0.007) and sexual dysfunction (SD, OR: 1.0931, 95% CI: 1.0292-1.1610, p = 0.004). Intriguingly, COVID-19 might exert a slight causal protective effect on the progression of urinary tract infections (UTIs) and bladder cancer (BLCA). These results were robust to sensitivity analyses. Bioinformatic analyses indicated that the inflammatory-immune response module may mediate the links between COVID-19 and its associated disorders at the molecular level.

Conclusions

In response to post-COVID-19 symptoms, we recommend that COVID-19 patients should strengthen the prevention of LUTC and the monitoring of sexual function. Meanwhile, the positive effects of COVID-19 on UTIs and BLCA should attach equal importance.

Platelet Membrane Cloaked Nanotubes to Accelerate Thrombolysis by Thrombus Clot-Targeting and Penetration

Thrombotic diseases have a high rate of mortality and disability, and pose a serious threat to global public health. Currently, most thrombolytic drugs especially protein drugs have a short blood-circulation time, resulting in low thrombolytic efficiency. Therefore, a platelet membrane (Pm) cloaked nanotube (NT-RGD/Pm) biomimetic delivery system with enhanced thrombolytic efficiency is designed. Nanotubes (NT) with an excellent clot-penetration properties are used to load a protein thrombolytic drug urokinase (Uk). Platelet-targeting arginine glycine-aspartic peptide (RGD) is grafted onto the surface of the nanotubes (NT-RGD) prior to cloaking. Multiple particle tracking (MPT) technique and confocal laser scanning microscope (CLSM) analysis are applied and the results show that the nanotubes possess a strong penetration and diffusion capacity in thrombus clots. After the Pm cloaking on NT-RGD/Uk, it shows a thrombus microenvironmental responsive release property and the half-life of Uk is six times longer than that of free Uk. Most importantly, NT-RGD-Uk/Pm exhibits a 60% thrombolytic efficiency in the FeCl₃ -induced thrombosis mouse model, and it is able to significantly reduce the bleeding side effects of Uk. This Pm-cloaked nanotube system is an effective and promising platform for the controlled and targeted delivery of drugs for the thrombus treatment.

Association Between the Use of Pre- and Post-thrombolysis Anticoagulation With All-Cause Mortality and Major Bleeding in Patients With Pulmonary Embolism

Objective

To explore the comparative clinical efficacy and safety outcomes of anticoagulation before (pre-) or following (post-) thrombolytic therapy in systemic thrombolytic therapy for pulmonary embolism (PE).

Methods

PubMed, the Cochrane Library, EMBASE, EBSCO, Web of Science, and CINAHL databases were searched from inception through 1 May 2021. All randomized clinical trials comparing systemic thrombolytic therapy vs. anticoagulation alone in patients with PE and those that were written in English were eligible. The primary efficacy and safety outcomes were all-cause mortality and major bleeding, respectively. Odds ratios (OR) estimates and associated 95% confidence intervals (CIs) were calculated. A Bayesian network analysis was performed using R studio software, and then the efficacy and safety rankings were derived.

Results

This network meta-analysis enrolled 15 trials randomizing 2,076 patients. According to the plot rankings, the anticoagulant therapy was the best in terms of major bleeding, and the post-thrombolysis anticoagulation was the best in terms of all-cause mortality. Taking major bleeding and all-cause mortality into consideration, the most safe–effective treatment was the post-thrombolysis anticoagulation in patients who needed thrombolytic therapy. The net clinical benefit analysis comparing associated ICH benefits vs. mortality risks of post-thrombolysis anticoagulation demonstrated a net clinical benefit of 1.74%.

Conclusion

The systemic thrombolysis followed by anticoagulation had a better advantage in all-cause mortality and major bleeding than the systemic thrombolysis before anticoagulation. The adjuvant anticoagulation treatment of systemic thrombolytic therapy should be optimized.

Enzyme Catalysis Biomotor Engineering of Neutrophils for Nanodrug Delivery and Cell-Based Thrombolytic Therapy

Utilizing neutrophils (NEs) to target and deliver nanodrugs to inflammation sites has received considerable attention. NEs are involved in the formation and development of thrombosis by transforming into neutrophil extracellular traps (NETs); this indicates that NEs may be a natural thrombolytic drug delivery carrier. However, NEs lack an effective power system to overcome blood flow resistance and enhance targeting efficiency. Herein, we report the application of a urease catalysis micromotor powered NEs nanodrug delivery system to promote thrombolysis and suppress rethrombosis. The urease micromotor powered Janus NEs (UM-NEs) were prepared by immobilizing the enzyme asymmetrically onto the surface of natural NEs and then loading urokinase (UK) coupled silver (Ag) nanoparticles (Ag-UK) to obtain the UM-NEs (Ag-UK) system. Urease catalytic endogenous urea is used to generate thrust by producing ammonia and carbon dioxide, which propels NEs actively targeting the thrombus. The UM-NEs (Ag-UK) can be activated by enriched inflammatory cytokines to release NETs at the thrombosis site, resulting in a concomitant release of Ag-UK. Ag-UK induces thrombolysis to restore vascular recanalization. This urease micromotor-driven NEs drug delivery system can significantly reduce the hemorrhagic side effects, promote thrombolysis, and inhibit rethrombosis with high bioavailability and biosafety, which can be used for the treatment of thrombotic diseases.

Successful Treatment of Massive Pulmonary Embolism with Rescue Fibrinolysis in Young Patient with Homocystinemia - Case Report

Pulmonary embolism (PE) is the most frequently missed diagnosis in the urgent clinical department with serious consequences. Patients with unprovoked PE have increased risk of recurrent PE. Approximately 5 to 8% of PE patients have inherited thrombophilias. A solated homocystinemia is a rare cause of unprovoked acute pulmonary embolism. Timely diagnosis and proper treatment can prevent complications, costs and mortality and provide patient better quality of life. We are presenting a 42-year-old woman was admitted to our emergency department with the first episode of severe dyspnea and chest pain. She had no history of previous cardiovascular or respiratory disease and no history of previous pulmonary embolism (PE) or deep vein thrombosis (DVT). Urgent echocardiography showed indirect signs of pulmonary embolism which was confirmed by the pulmonary artery CT angiography performed one day after the patient’s admission. After two days of heparin infusion, she developed a hemodynamic instability with cardiogenic shock and was treated successfully with fibrinolysis. After the clinical stabilization, she was put on the rivaroxaban therapy, which was recommended for additional six months. The thrombophilia profile was done two weeks after stopping the therapy with rivaroxaban. The thrombophilia panel came back positive for high levels of homocysteine (67 μmol/L), with other thrombophilia results within normal limits. The patient was stable during the follow-up period. Pulmonary embolism should be always suspected in younger patients with acute severe dyspnea even without provocable risk factors. High suspicion level and fast diagnosis are lifesaving. In younger patients presented with unprovoked pulmonary embolism, clinicians should consider inherited prothrombotic factors and homocystinemia as a potential cause. Rescue fibrinolysis is a lifesaving therapy in hemodynamic worsening in intermediate high-risk PE patients. A longer anticoagulation therapy should be considered in these cases with novel oral anticoagulants that are recommended as safer and superior therapy.

The net benefit of thrombolysis in the management of intermediate risk pulmonary embolism: Systematic review and meta-analysis

Background

Benefit of thrombolytic therapy in patients with massive pulmonary embolism (PE) is evident. However, evidence supporting benefit in clinical outcomes of this approach in intermediate risk PE is lacking.

Objective

To determine the impact of thrombolysis on overall survival in intermediate risk PE patients.

Methods

We searched in MEDLINE (OVID), EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials (CENTRAL) from present day. We also searched in other databases and unpublished literature. We included clinical trials without language restrictions. The risk of bias was evaluated with the Cochrane Collaboration's tool. The primary outcome was overall survival. Secondary outcomes were adverse events, including major bleeding, and all-cause mortality. The measure of the effect was the risk ratio with a 95% confidence interval (CI).

Results

We included 11 studies in the qualitative and quantitative analysis, with a total of 1855 patients. Risk of bias was variable among the study items. There were no results reported about overall survival in any of the studies. The risk ratio (RR) for all-cause mortality was 0.68 95% CI (0.40 to 1.16). The RR of overall bleeding, major bleeding and stroke were 2.72 95% CI (1.58 to 4.69), 2.17 95% CI (1.03 to 4.55), and 2.22 95% CI (0.17 to 28.73), respectively. Additionally, the RR for recurrent PE was 0.56 95% CI (0.23 to 1.37).

Conclusions

In patients with intermediate risk PE, the risk of bleeding is higher when thrombolysis is used. There was no significant difference between thrombolysis and anticoagulation in recurrence of PE, stroke, and all-cause mortality.

Fibrinolytics for the treatment of pulmonary embolism

The use of fibrinolytic agents in acute pulmonary embolism (PE), first described over 50 years ago, hastens the resolution of RV stain, leading to earlier hemodynamic improvement. However, this benefit comes at the increased risk of bleeding. The strongest indication for fibrinolysis is in high-risk PE, or that characterized by sustained hypotension, while its use in patients with intermediate-risk PE remains controversial. Fibrinolysis is generally not recommended for routine use in intermediate-risk PE, although most guidelines advise that it may be considered in patients with signs of acute decompensation and an overall low bleeding risk. The efficacy of fibrinolysis often varies significantly between patients, which may be at least partially explained by several factors found to promote resistance to fibrinolysis. Ultimately, treatment decisions should carefully weigh the risks and benefits of the individual clinical scenario at hand, including the overall severity, the patient's bleeding risk, and the presence of factors known to promote resistance to fibrinolysis. This review aims to further explore the use of fibrinolytic agents in the treatment of PE including specific indications, outcomes, and special considerations.

Left Ventricular Dysfunction Correlates With Mortality in Pulmonary Embolism

BACKGROUND

Risk stratification of patients with pulmonary embolism (PE) is essential to guide advanced interventional management and proper disposition.

OBJECTIVES

In this study, we sought to assess individual echocardiographic markers of right ventricular (RV) strain and left ventricular (LV) function in patients with high-risk PE and identify their association with the need for advanced intervention (such as thrombolysis) and 30-day mortality.

METHODS

This was a retrospective study of ED patients with PE who were subject to a pulmonary embolism response team activation over a 5-year period. Cardiac point-of-care ultrasound studies were performed as part of patient care and later assessed for septal bowing, RV hypokinesis, McConnell sign, RV enlargement, tricuspid annular place systolic excursion, and LV systolic dysfunction. Outcome variables included need for advanced intervention and 30-day mortality.

RESULTS

The pulmonary embolism response team was activated in 893 patients, of which 718 had a confirmed PE. Of these, 90 had adequate cardiac point-of-care ultrasound images available for review. Patients who needed an advanced intervention were more likely to have septal bowing (odds ratio [OR] 8.69, 95% confidence interval [CI] 2.37-31.86), RV enlargement (OR 4.02, 95% CI 1.43-11.34), and a McConnell sign (OR 2.79, 95% CI 1.09-7.13). LV dysfunction was the only statistically significant predictor of 30-day mortality (OR 9.63, 95% CI 1.74-53.32).

CONCLUSION

In patients with PE in the ED, sonographic findings of RV strain that are more commonly associated with advanced intervention included septal bowing, McConnell sign, and RV enlargement. LV dysfunction was associated with a higher 30-day mortality. These findings can help inform decisions about ED management and disposition of patients with PE.

Management of antithrombotic therapy in gray areas of venous thromboembolism: a Delphi consensus panel

For some years now, direct-acting oral anticoagulants (DOACs) have entered the clinical practice for stroke prevention in non-valvular atrial fibrillation (NVAF) or for prevention and treatment of venous thromboembolism (VTE). However, there is uncertainty on DOACs' use in some clinical scenarios that are not fully explored by clinical trials, but commonly encountered in the real world. We report a Delphi Consensus on DOAC use in VTE patients. The consensus dealt with seven main topics: (1) clinical superiority of DOACs compared to VKAs; (2) therapeutic options for patients with intermediate risk PE; (3) therapeutic management of patients with deep vein thrombosis (DVT); (4) DOACs' role in oncological patients with VTE; (5) role of the reversal agent; (6) safety of low doses of DOACs in VTE patients; (7) DOACs long-term therapy (more than 12 months) in VTE patients; Forty-six physicians (cardiologists, internists, angiologists, oncologists, hematologists, and geriatricians) from Italy expressed their level of agreement on each statement by using a five-point Likert scale (1: strongly disagree, 2: disagree, 3: somewhat agree, 4: agree, 5: strongly agree). Votes 1-2 were considered as disagreement, while votes 3-5 as agreement. For each statement an agreement of ≥ 66% among the respondents was considered consensus. A brief discussion about the results for each topic is also reported.

Novel antithrombotic strategies for treatment of venous thromboembolism

Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), is the third most common cause of vascular death after heart attack and stroke. Anticoagulation therapy is the cornerstone of VTE treatment. Despite such therapy, up to 50% of patients with DVT develop postthrombotic syndrome, and up to 4% of patients with PE develop chronic thromboembolic pulmonary hypertension. Therefore, better therapies are needed. Although direct oral anticoagulants are more convenient and safer than warfarin for VTE treatment, bleeding remains the major side effect, particularly in cancer patients. Factor XII and factor XI have emerged as targets for new anticoagulants that may be safer. To reduce the complications of VTE, attenuation of thrombin activatable fibrinolysis inhibitor activity is under investigation in PE patients to enhance endogenous fibrinolysis, whereas blockade of leukocyte interaction with the vessel wall is being studied to reduce the inflammation that contributes to postthrombotic syndrome in DVT patients. Focusing on these novel antithrombotic strategies, this article explains why safer anticoagulants are needed, provides the rationale for factor XII and XI as targets for such agents, reviews the data on the factor XII- and factor XI-directed anticoagulants under development, describes novel therapies to enhance fibrinolysis and decrease inflammation in PE and DVT patients, respectively, and offers insights into the opportunities for these novel VTE therapies.

Thrombolysis in Pulmonary Embolism: An Evidence-Based Approach to Treating Life-Threatening Pulmonary Emboli

Acute pulmonary embolism (PE) is associated with high in-hospital morbidity and mortality, both via cardiorespiratory decompensation and the bleeding complications of treatment. Thrombolytic therapy can be life-saving in those with high-risk PE, but requires careful patient selection. Patients with PE and systemic arterial hypotension ("massive PE") should receive thrombolytic therapy unless severe contraindications are present. Patients with PE and right ventricular dysfunction/injury, but without hypotension ("submassive PE"), should be considered for thrombolysis on a case-by-case basis, considering bleeding risk, cardiac biomarkers, echocardiography, and most importantly, clinical status.

Concise Review of the Clinical Approach to the Exclusion and Diagnosis of Pulmonary Embolism in 2020

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.

Local Thrombolysis in High-Risk Pulmonary Embolism-13 Years Single-Center Experience

To evaluate the prognosis after local thrombolysis compared to systemic thrombolysis in high-risk pulmonary embolism. Observational study during 13 years which included 37 patients with high-risk pulmonary embolism treated with local thrombolysis and 36 patients with systemic thrombolysis (streptokinase, 250 000 UI/30 minutes followed by 100 000 UI/h). Cardiogenic shock has totally remitted in the group with local thrombolysis (P = .002). The decrease in pressure gradient between right ventricle and right atrium was comparable in both groups in the acute period (the results being influenced by the higher in-hospital mortality after systemic thrombolysis), but significantly better in the next 24 months follow-up after in situ thrombolysis. Major and minor bleeding did not have significant differences. In hospital, mortality was significantly lower in the group with local thrombolysis (P = .003), but for the next 24 months follow-up, the survival was comparable in both groups. Local thrombolysis, during the hospitalization, was associated with lower mortality rate comparing with systemic thrombolysis. In the next 24 months follow-up, the evolution of residual pulmonary hypertension was significantly better after in situ thrombolysis.

Lifting the fog in intermediate-risk (submassive) PE: full dose, low dose, or no thrombolysis?

Acute pulmonary embolism (PE) is a disease frequently encountered in clinical practice. While the management of haemodynamically stable, low risk patients with acute PE is well established, managing intermediate disease often presents a therapeutic dilemma. In this review, we discuss the various therapeutic options available in this patient group. This includes thrombolysis, surgical embolectomy and catheter directed techniques. We have also explored the role of specialist PE response teams in the management of such patients. ​.

Prise en charge de l'embolie pulmonaire grave en réanimation

L'embolie pulmonaire (EP) grave, définie par la présence d’un état de choc, est à l'origine d'une mortalité importante. L'objectif de cette mise au point est de synthétiser les dernières avancées et recommandations concernant la prise en charge des formes graves d'EP. La stratification du risque individuel de mortalité précoce permet d'apporter une stratégie diagnostique et thérapeutique optimisée pour chaque patient. Le traitement symptomatique consiste essentiellement en la prise en charge de l'état de choc. L'anticoagulation curative par héparine non fractionnée est réservée aux patients hémodynamiquement instables. Chez ces patients à haut risque, la thrombolyse systémique diminue la mortalité et le risque de récidive d'EP. Chez les patients à risque intermédiaire élevé, la thrombolyse systémique à dose standard diminue le risque de choc secondaire mais sans impact sur la mortalité globale. La thrombolyse est donc réservée aux patients à risque intermédiaire élevé présentant secondairement un état de choc. L'embolectomie chirurgicale reste indiquée en cas de contre-indication absolue à la thrombolyse ou en cas d'échec de celle-ci. Le positionnement dans l'algorithme thérapeutique de l'assistance extracorporelle et des techniques percutanées de revascularisation reste à définir. Leurs indications doivent donc être discutées dans des centres experts après une concertation multidisciplinaire incluant pneumologues, cardiologues, réanimateurs, radiologues interventionnels et chirurgiens cardiaques.

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Surgical pulmonary embolectomy and catheter-directed thrombolysis for treatment of submassive pulmonary embolism

BACKGROUND

Acute pulmonary embolism (PE) with preserved hemodynamics but right ventricular dysfunction, classified as submassive PE, carries a high risk of mortality. We report the results for patients who did not qualify for medical therapy and required treatment of submassive PE with surgical pulmonary embolectomy and catheter-directed thrombolysis (CDT).

METHODS

Between October 1999 and May 2015, 133 submassive PE patients underwent treatment with pulmonary embolectomy (71) and CDT (62). A multidisciplinary PE response team helped to determine the most appropriate treatment strategy on a case-by-case basis. The EkoSonic ultrasound-facilitated thrombolysis system (EKOS) was used for CDT, which was introduced in 2010.

RESULTS

The mean age of submassive PE patients was 57.3 years, which included 36.8% females. PE risk factors included previous deep venous thrombosis (46.6%), immobility (36.1%), recent surgery (30.8%), and cancer (22.6%), P < 0.05. The most common indication for advanced treatment was right ventricular strain (42.9%), P = 0.03. The frequency of surgical pulmonary embolectomy remained stable even after incorporating the EKOS procedure into our treatment algorithm, with statistically similar operative mortality. Bleeding was observed in six CDT patients and one pulmonary embolectomy patient (P < 0.05). Follow-up echocardiography was available for 61% of the overall cohort, of whom 76.5% had no residual moderate or severe right ventricular dysfunction.

CONCLUSIONS

Pulmonary embolectomy and CDT are important contemporary advanced treatment options for selected high-risk patients with submassive PE, who do not qualify for medical therapy.

Understanding haemorrhagic risk following thrombolytic therapy in patients with intermediate-risk and high-risk pulmonary embolism: a hypothesis paper

While systemic intravenous thrombolysis decreases mortality in patients with high-risk pulmonary embolism (PE), it clearly increases haemorrhagic risk. There are many contraindications to thrombolysis, and efforts should aim at selecting those patients who will benefit most, without suffering complications. The current review summarises the evidence for the use of thrombolytic therapy in PE. It clarifies the pathophysiological mechanisms in PE and acute cor pulmonale that increase the risk of bleeding following thrombolysis. It discusses future management challenges, namely tailored drug administration, new treatment monitoring techniques and catheter-directed thrombolysis.

Successful Treatment of Refractory Massive Pulmonary Embolism with Repeated Administration of Systemic Thrombolysis

BACKGROUND

We report a case series of two patients in the intensive care unit with massive pulmonary embolism and obstructive shock who had resolution of shock after repeated administration of alteplase.

CASE SUMMARIES

Both patients were initially dosed 10 mg of alteplase followed by infusion of 90 mg over 2 hours, but remained in obstructive shock requiring significant inotropic and vasopressor support. Both patients were deemed poor candidates for embolectomy. The first patient received repeated doses reaching an accumulative dose of 200 mg alteplase over 15 hours. The second patient received an accumulative dose of 250 mg alteplase over 36 hours. Both patients had resolution of shock within 24 hours of repeated administration of alteplase, but also experienced significant drops in hemoglobin, which were supported with transfusions. They were transferred out of the intensive care unit after resolution of obstructive shock and hemorrhage. The first patient died one week after transfer from the intensive care unit due to invasive candidiasis and septic shock. The second patient was weaned from the ventilator and discharged home.

CONCLUSION

Patients with obstructive shock secondary to massive pulmonary embolism despite a one-time dose of alteplase and poor candidacy for embolectomy may benefit from repeated doses of alteplase. Due to the short half-life, repeated administration of thrombolytic may be appropriate for younger patients without absolute contraindications to thrombolysis, but future studies are needed to identify the optimal patient population.

Venous Thromboembolism and Pulmonary Embolism Response Teams: An Overview

Venous thromboembolism is a common disease with a wide array of signs and symptoms. It has been cited as the third leading cause of cardiovascular death, and if left untreated, it leads to death in 1 in 4 patients. Sophisticated diagnostic tools have allowed physician to become more accurate in diagnosing pulmonary embolism and deep vein thrombosis. The advent of new oral anticoagulants, the emergence of pulmonary embolism response teams, and protocols demonstrate recent achievements in the management of venous thromboembolism. The focus of this article is to discuss the treatment of venous thromboembolism.

Terapia fibrinolítica sistêmica no tromboembolismo pulmonar

O tromboembolismo pulmonar permanece como um grande desafio terapêutico para os médicos especialistas, pois, apesar de todo investimento e desenvolvimento em seu diagnóstico, profilaxia e tratamento, essa condição continua sendo a principal causa de morte evitável em ambiente hospitalar. Ainda restam muitas dúvidas em relação a qual perfil de paciente vai se beneficiar de fato da terapia fibrinolítica sistêmica, sem ficar exposto a um grande risco de sangramento. A estratificação de risco e a avaliação do prognóstico do evento, através de escores clínicos de insuficiência ventricular direita, marcadores de dilatação e disfunção do ventrículo direito e avaliação da massa trombótica, associados ou de forma isolada, são ferramentas que podem auxiliar na identificação do paciente que irá se beneficiar dessa terapia. Os únicos consensos em relação à terapia fibrinolítica no tratamento do tromboembolismo pulmonar são: não deve ser indicada de forma rotineira; nenhum dos escores ou marcadores, isoladamente, devem justificar seu uso; e os pacientes com instabilidade hemodinâmica são os mais beneficiados. Além disto, deve-se avaliar cada caso em relação ao risco de sangramento, especialmente no sistema nervoso central.

On the right side of the heart: Medical and mechanical support of the failing right ventricle

Acute right ventricular failure remains an immensely challenging clinical condition associated with a high mortality rate. In this narrative review, we highlight the pathophysiological mechanisms underlying right ventricular failure and suggest an initial diagnostic approach to this critically ill group of patients. Based on the best available evidence and our cumulative clinical experience as a national cardiothoracic centre, we summarize the basic principles of medical management and mechanical salvage therapy, finalizing with a series of recommendations for the management of right ventricular failure in specific clinical scenarios.

Pediatric Thrombolysis: A Practical Approach

The incidence of pediatric venous thromboembolic disease is increasing in hospitalized children. While the mainstay of treatment of pediatric thrombosis is anticoagulation, reports on the use of systemic thrombolysis, endovascular thrombolysis, and mechanical thrombectomy have steadily been increasing in this population. Thrombolysis is indicated in the setting of life- or limb-threatening thrombosis. Thrombolysis can rapidly improve venous patency thereby quickly ameliorating acute signs and symptoms of thrombosis and may improve long-term outcomes such as postthrombotic syndrome. Systemic and endovascular thrombolysis can result in an increase in minor bleeding in pediatric patients, compared with anticoagulation alone, and major bleeding events are a continued concern. Also, endovascular treatment is invasive and requires technical expertise by interventional radiology or vascular surgery, and such expertise may be lacking at many pediatric centers. The goal of this mini-review is to summarize the current state of knowledge of thrombolysis/thrombectomy techniques, benefits, and challenges in pediatric thrombosis.

In-Hospital Management and Follow-Up Treatment of Venous Thromboembolism: Focus on New and Emerging Treatments

Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep venous thrombosis (DVT), is a major cause of morbidity and mortality of particular relevance for intensivists and hospitalists. Acute VTE is usually managed with parenteral unfractionated heparin or low-molecular-weight heparin, followed by an oral vitamin K antagonist. Data are lacking for optimal treatment of less common occurrences, such as upper extremity DVT, and for approaches such as thrombolysis for PE associated with early signs of hemodynamic compromise or inferior vena cava filters when anticoagulation is contraindicated. Direct oral anticoagulants (DOACs) including apixaban, dabigatran, edoxaban, and rivaroxaban are now added to the armamentarium of agents available for acute management of VTE and/or reducing the risk of recurrence. This review outlines an algorithmic approach to acute VTE treatment: from aggressive therapies when anticoagulation may be inadequate, to alternative choices when anticoagulation is contraindicated, to anticoagulant options in the majority of patients in whom anticoagulation is appropriate. Evidence-based guidelines and the most recent DOAC clinical trial data are discussed in the context of the standard of care. Situations and treatment approaches for which data are unavailable or insufficient are identified. VTE therapy in care transitions is discussed, as are choices for secondary prevention.

Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report

BACKGROUND

We update recommendations on 12 topics that were in the 9th edition of these guidelines, and address 3 new topics.

METHODS

We generate strong (Grade 1) and weak (Grade 2) recommendations based on high- (Grade A), moderate- (Grade B), and low- (Grade C) quality evidence.

RESULTS

For VTE and no cancer, as long-term anticoagulant therapy, we suggest dabigatran (Grade 2B), rivaroxaban (Grade 2B), apixaban (Grade 2B), or edoxaban (Grade 2B) over vitamin K antagonist (VKA) therapy, and suggest VKA therapy over low-molecular-weight heparin (LMWH; Grade 2C). For VTE and cancer, we suggest LMWH over VKA (Grade 2B), dabigatran (Grade 2C), rivaroxaban (Grade 2C), apixaban (Grade 2C), or edoxaban (Grade 2C). We have not changed recommendations for who should stop anticoagulation at 3 months or receive extended therapy. For VTE treated with anticoagulants, we recommend against an inferior vena cava filter (Grade 1B). For DVT, we suggest not using compression stockings routinely to prevent PTS (Grade 2B). For subsegmental pulmonary embolism and no proximal DVT, we suggest clinical surveillance over anticoagulation with a low risk of recurrent VTE (Grade 2C), and anticoagulation over clinical surveillance with a high risk (Grade 2C). We suggest thrombolytic therapy for pulmonary embolism with hypotension (Grade 2B), and systemic therapy over catheter-directed thrombolysis (Grade 2C). For recurrent VTE on a non-LMWH anticoagulant, we suggest LMWH (Grade 2C); for recurrent VTE on LMWH, we suggest increasing the LMWH dose (Grade 2C).

CONCLUSIONS

Of 54 recommendations included in the 30 statements, 20 were strong and none was based on high-quality evidence, highlighting the need for further research.