1
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Tan JS, Liu N, Hu S, Wu Y, Gao X, Guo TT, Yan XX, Peng FH, Hua L. Association Between the Use of Pre- and Post-thrombolysis Anticoagulation With All-Cause Mortality and Major Bleeding in Patients With Pulmonary Embolism. Front Cardiovasc Med 2022; 9:880189. [PMID: 35845061 PMCID: PMC9279684 DOI: 10.3389/fcvm.2022.880189] [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: 02/21/2022] [Accepted: 05/27/2022] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Jiang-Shan Tan
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ningning Liu
- Peking University Sixth Hospital/Institute of Mental Health, Beijing, China
- National Health Council Key Laboratory of Mental Health (Peking University), National Clinical Research Center for Mental Disorders, Peking University Sixth Hospital, Beijing, China
| | - Song Hu
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Wu
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin Gao
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ting-Ting Guo
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xin-Xin Yan
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fu-Hua Peng
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Hua
- Center for Respiratory and Pulmonary Vascular Diseases, Department of Cardiology, Key Laboratory of Pulmonary Vascular Medicine, National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- *Correspondence: Lu Hua,
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2
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Lillyblad MP, Qadri GA, Weise BE, Smith CS, St Hill C, Tierney DM, Melamed RR. Post-thrombolytic coagulopathy and complications in patients with pulmonary embolism treated with fixed-dose systemic alteplase. J Thromb Thrombolysis 2022; 54:605-615. [PMID: 35320471 DOI: 10.1007/s11239-022-02640-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Alteplase treatment can cause a systemic coagulopathy although the incidence and contributory factors are unknown in pulmonary embolism (PE). Fixed-dosing of alteplase for PE may lead to interpatient variability in drug exposure and influence post-thrombolytic coagulopathy (PTC). While changes in fibrinogen and INR have been used to describe PTC, no universal PTC definition is available. OBJECTIVES Evaluate the incidence of PTC after alteplase treatment for PE, the effect of patient weight and blood/plasma volume and the association with bleeding complications. METHODS We conducted a retrospective cohort study of patients treated with alteplase for massive or high-risk submassive PE. Demographics, alteplase dosing, laboratory assessment of coagulopathy, and bleeding events were collected. The primary endpoint was incidence of PTC defined as an international normalized ratio (INR) > 1.5 or fibrinogen < 170 mg/dL. Secondary outcomes included correlation between coagulopathies and alteplase dose normalized to actual body weight (ABW), ideal body weight (IBW), plasma volume (PV), and estimated blood volume (EBV). Bleeding events in patients with and without PTC were compared. RESULTS 125 patients met criteria for inclusion in the study. PTC occurred in 35.3% of patients, with INR >1.5 in 21.8% and fibrinogen <170 mg/dL in 26%. Alteplase dose >50 mg was associated with increased odds of PTC (OR 6.5, CI 2.1-19.9). Dose normalized to ABW and EBV correlated weakly with absolute increase in post-alteplase INR (r =0.20, p =0.06 and r =0.21, p =0.057 respectively) and to percent change in INR (r =0.20, p = 0.058 and r =0.21, p =0.048 respectively). Dose/ABW, dose/PV, and dose/EBV each correlated moderately with absolute decrease in fibrinogen (r =-0.53, -0.49, and -0.47 respectively, p <0.001 for each) and percent change in fibrinogen (r = -0.55, -0.49, and -0.49 respectively, p < 0.001 for each). Dose/IBW correlated weakly with absolute and percent decrease in fibrinogen (r = -0.32, p =0.013 and r =-0.33, p =0.011). Patients with bleeding were more likely to have PTC (58.3% vs. 28.6%, p= 0.05) and a bleeding event was predictive of PTC (OR 5.33, 1.32-23.99). CONCLUSIONS PTC is prevalent in patients with PE. PTC is influenced by alteplase dose and exposure parameters (ABW, IBW, PV, EBV) and may contribute to the bleeding risk.
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Affiliation(s)
- Matthew P Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, 800 East 28th Street - MR 11321, 55407, Minneapolis, MN, USA.
| | - Ghaziuddin A Qadri
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Brynn E Weise
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Claire S Smith
- Care Delivery Research, Allina Health, Minneapolis, MN, USA
| | | | - David M Tierney
- Department of Medical Education, Abbott Northwestern Hospital, Minneapolis, MN, USA
| | - Roman R Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Minneapolis, MN, USA
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3
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Hinds MT, Kaul S. Response to commentary on JTH-2020-01486.R1 - Quantification of microbubble-induced sonothrombolysis in an ex-vivo non-human primate model. J Thromb Haemost 2021; 19:874-875. [PMID: 33650254 DOI: 10.1111/jth.15225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 12/21/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Monica T Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, OR, USA
| | - Sanjiv Kaul
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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4
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Hinds MT, Ammi AY, Johnson J, Kaul S. Quantification of microbubble-induced sonothrombolysis in an ex vivo non-human primate model. J Thromb Haemost 2021; 19:502-512. [PMID: 33205492 PMCID: PMC8591990 DOI: 10.1111/jth.15180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND In vitro studies with ultrasound (US) and microbubbles (MB) have reported that sono-thrombolysis can be achieved at high peak rarefactional acoustic pressure amplitudes (PRAPAs) using 0.25 and 1.05 MHz US frequencies. OBJECTIVE The aim of the current study was to determine if these parameters work on an ex vivo physiological model of thrombosis. METHODS A thrombogenic device was placed in an ex vivo chronic arteriovenous shunt in juvenile baboons. Platelet accumulation was measured by dynamic imaging of the device and the 10 cm thrombus tail with 111 In-labeled platelets. After 15 minutes of thrombus formation, treatment with either low-dose recombinant tissue plasminogen activator (rtPA) or low-dose rtPA + MB+US was performed for 20 minutes. Four US settings at 0.25% duty cycle were used: 0.25 MHz at PRAPAs of 1.20 and 2.20 MPa, and 1.05 MHz at 1.75 and 4.75 MPa. RESULTS Platelet accumulation was not inhibited by low-dose rtPA or MB with US alone. Platelet accumulation was significantly reduced with 0.25 MHz US at 2.20 PRAPA (P < .001) and with 1.05 MHz at 1.75 MPa and 4.75 MPa (P < .05) when used with MB and low-dose rtPA. Although this approach prevented platelet accumulation it did not cause thrombolysis on the device. CONCLUSIONS rtPA + MB + US (0.25 and 1.05 MHz) resulted in inhibition of platelet accumulation on the thrombogenic device when moderately high PRAPAs (≥1.75 MPa) were used. These results taken in context with lytic effects of US on myocardial microthrombi and direct effect on myocardial blood flow and function provide direction for the use of therapeutic US in acute coronary syndromes.
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Affiliation(s)
- Monica T. Hinds
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Azzdine Y. Ammi
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Jennifer Johnson
- Department of Biomedical Engineering, Oregon Health & Science University, Portland, Oregon, USA
| | - Sanjiv Kaul
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
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5
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6
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Prasad K, Singh P, Kanabar K, Vijayvergiya R. Pulmonary haemorrhage following thrombolysis with streptokinase in myocardial infarction. BMJ Case Rep 2020; 13:13/1/e232308. [PMID: 31980474 DOI: 10.1136/bcr-2019-232308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Pulmonary haemorrhage is a rare but a life-threatening complication of thrombolytic therapy in patients with acute ST-elevation myocardial infarction (MI). It usually presents with anaemia, massive haemoptysis, acute-onset respiratory distress and diffuse bilateral lung infiltrates on imaging. We hereby describe two patients, who had pulmonary haemorrhage following streptokinase therapy for acute MI. The first patient improved with conservative treatment, while the second patient died due to respiratory failure. Streptokinase, a fibrin non-specific agent, is a widely used thrombolytic in low-income and middle-income countries. Pulmonary haemorrhage should be suspected in patients who develop sudden respiratory compromise after receiving thrombolytics, especially streptokinase. The management issues related to this uncommon life-threatening complication have been discussed in this article.
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Affiliation(s)
- Krishna Prasad
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Parminder Singh
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kewal Kanabar
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Vijayvergiya
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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7
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Atmaca MM, Simsek UB, Midi I, Aliev R, Aytac E, Kocaturk M. Diffuse alveolar hemorrhage following intravenous thrombolytic treatment in acute ischemic stroke: a case series. Neurol Sci 2019; 41:233-237. [PMID: 31280387 DOI: 10.1007/s10072-019-03997-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/26/2019] [Indexed: 11/25/2022]
Abstract
Diffuse alveolar hemorrhage (DAH) following fibrinolytic therapy is a rare but a life-threatening complication. In acute ischemic stroke (AIS), DAH as a complication was not reported following intravenous thrombolytic therapy (ITT). The demographic, clinical, radiologic, and prognostic data of 4 patients with AIS who developed DAH after ITT are presented in this case series, along with a literature review.
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Affiliation(s)
- Murat Mert Atmaca
- Department of Neurology, Istanbul Sultan Abdulhamid Han Training and Research Hospital, Selimiye Quarter, Tibbiye Avenue, 34668, Uskudar, Istanbul, Turkey.
| | - Ugur Burak Simsek
- Department of Neurology, Istanbul Sultan Abdulhamid Han Training and Research Hospital, Selimiye Quarter, Tibbiye Avenue, 34668, Uskudar, Istanbul, Turkey
| | - Ipek Midi
- Department of Neurology, Istanbul Pendik Training and Research Hospital, Marmara University, Fevzi Cakmak Quarter, Muhsin Yazicioglu Avenue, No. 10, 34899, Pendik, Istanbul, Turkey
| | - Rustem Aliev
- Department of Neurology, Istanbul Pendik Training and Research Hospital, Marmara University, Fevzi Cakmak Quarter, Muhsin Yazicioglu Avenue, No. 10, 34899, Pendik, Istanbul, Turkey
| | - Emrah Aytac
- Department of Neurology, Firat University Hospital, University Quarter, Yunus Emre Avenue, No. 20, 23200, Elazıg, Turkey
| | - Mehtap Kocaturk
- Department of Neurology, Harran University Research and Application Hospital, Osmanbey Campus, 63300, Sanliurfa, Turkey
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8
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Abraham P, Arroyo DA, Giraud R, Bounameaux H, Bendjelid K. Understanding haemorrhagic risk following thrombolytic therapy in patients with intermediate-risk and high-risk pulmonary embolism: a hypothesis paper. Open Heart 2018. [PMID: 29531763 PMCID: PMC5845427 DOI: 10.1136/openhrt-2017-000735] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
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.
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Affiliation(s)
- Paul Abraham
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Diego A Arroyo
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Department of Cardiology, University and Hospital Fribourg, Fribourg, Switzerland
| | - Raphael Giraud
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
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9
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Narayanan S, Thulaseedharan NK, Subramaniam G, Panarkandy G, Arathi N. Pulmonary alveolar hemorrhage following thrombolytic therapy. Int Med Case Rep J 2017; 10:123-125. [PMID: 28435331 PMCID: PMC5388342 DOI: 10.2147/imcrj.s129087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
We report a case of a 58-year-old male without any comorbidities who was thrombolysed with streptokinase for acute anterior wall myocardial infarction and developed massive hemoptysis with dyspnea and imaging features showing bilateral alveolar infiltrates. He was diagnosed with pulmonary alveolar hemorrhage and treated conservatively. His condition improved, and follow-up imaging showed resolution. Alveolar hemorrhage is a rare and life-threatening complication of thrombolytic therapy.
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Affiliation(s)
| | | | - Gomathy Subramaniam
- Department of Radiodiagnosis, Government Medical College, Kozhikode, Kerala, India
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10
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Patel AK, Kafi A, Bonet A, Shapiro SM, Oh SS, Zeidler MR, Betancourt J. Resolution of a Mobile Right Atrial Thrombus Complicating Acute Pulmonary Embolism With Low-Dose Tissue Plasminogen Activator in a Patient With Recent Craniotomy. J Intensive Care Med 2016; 31:618-21. [PMID: 27139009 DOI: 10.1177/0885066616646539] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 04/06/2016] [Indexed: 11/17/2022]
Abstract
Right heart thrombus in transit (RHTT) is a rare, severe form of venous thromboembolism that carries a high mortality rate. The optimal treatment for RHTT has not been well established. Thrombolysis is a therapeutic modality for RHTT but carries the risk of bleeding complications including intracranial hemorrhage. Low-dose thrombolysis has been shown to be effective in treating submassive pulmonary emboli without an increased risk in bleeding complications, but it has not been studied in patients with RHTT. Here, we discuss the case of a 74-year-old male with lung cancer and recent craniotomy with metastasectomy 30 days prior to admission presenting with RHTT and bilateral pulmonary emboli (PE). He was treated successfully with low-dose thrombolysis, despite his relative contraindication to thrombolytics. To our knowledge, this is the first reported case of low-dose alteplase (tissue plasminogen activator [tPA]) used to treat an in-transit PE in the setting of recent craniotomy with metastasectomy.
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Affiliation(s)
- Amisha K Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Aarya Kafi
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Antonio Bonet
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Shelly M Shapiro
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Scott S Oh
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Michelle R Zeidler
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jaime Betancourt
- Pulmonary and Critical Care Section, Department of Medicine, West Los Angeles Veterans Affairs Healthcare Center and the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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11
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Mahjoob MP, Khaheshi I, Paydary K. Diffuse pulmonary hemorrhage after fibrinolytic therapy for acute myocardial infarction in a cocaine abuser patient. Heart Views 2014; 15:83-5. [PMID: 25538823 PMCID: PMC4268617 DOI: 10.4103/1995-705x.144797] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a 45-year-old man with antroseptal myocardial infarction who developed bilateral basal alveolar infiltrates after initiating the fibrinolytic therapy. Although thrombolytic therapy with streptokinase is generally used in the course of acute myocardial infarction and has diminished morbidity and mortality, pulmonary hemorrhage is an uncommon, but a potentially life-threatening complication that should be regarded as one of the differential diagnoses of pulmonary infiltrates or dropping hemoglobin with no apparent bleeding site.
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Affiliation(s)
- Mohammad Parsa Mahjoob
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Isa Khaheshi
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Koosha Paydary
- Students Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
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12
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Hubbard J, Saad WEA, Sabri SS, Turba UC, Angle JF, Park AW, Matsumoto AH. Rheolytic Thrombectomy with or without Adjunctive Indwelling Pharmacolysis in Patients Presenting with Acute Pulmonary Embolism Presenting with Right Heart Strain and/or Pulseless Electrical Activity. THROMBOSIS 2011; 2011:246410. [PMID: 22254138 PMCID: PMC3255315 DOI: 10.1155/2011/246410] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Accepted: 07/20/2011] [Indexed: 12/13/2022]
Abstract
Purpose. To evaluate the safety and efficacy of the Possis rheolytic thrombectomy with or without indwelling catheter-directed pharmacolysis for the treatment of massive pulmonary embolus in patients presenting with right heart strain and/or a pulseless electrical activity (PEA). Materials and Methods. Retrospective review of patients undergoing pulmonary pharmacolysis was performed (07/2004-06/2009). Pre- and posttreatment Miller index scoring weres calculated and compared. Patients were evaluated for tPA doses, ICU stay, hospital stay, and survival by Kaplan-Meier analysis. Results. 11 patients with massive PE were found, with 10/11 presenting with a Miller score of >17 (range: 16-27, mean: 23.2). CTPA and/or echocardiographic evidence of right heart strain was found in 10/11 patients. 3 (27%) patients presented with a PEA event. Two (18%) patients had a contraindication to pharmacolysis and were treated with mechanical thrombectomy alone. The intraprocedural mortality was 9% (n = 1/11). Of the 10 patients who survived the initial treatment, 7 patients underwent standard mechanical thrombectomy initially, while 5 received power pulse spray mechanical thrombectomy. Eight of these 10 patients underwent adjunctive indwelling catheter-directed thrombolysis. The mean catheter-directed infusion duration was 18 hours (range of 12-26 hours). The average intraprocedural, infusion, and total doses of tPA were 7 mg, 19.7 mg, and 26.7 mg, respectively. There was a 91% (10/11) technical success rate. The failure was the single mortality. Average reduction in Miller score was 9.5 or 41% (P = 0.009), obstructive index of 6.4 or 47% (P = 0.03), and perfusion index of 2.7 or 28% (P = 0.05). Average ICU and hospital stay were 7.4 days (range 2-27 days) and 21.3 days (range 6-60 days), respectively. Intent to treat survival was 90% at 6, 12, and 18 months. Conclusion. Rheolytic thrombectomy with or without adjunctive catheter-directed thrombolysis provides a safe and effective method for treatment of acute PE in patients who present with right heart strain and/or a PEA event.
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Affiliation(s)
- J. Hubbard
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - W. E. A. Saad
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - S. S. Sabri
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - U. C. Turba
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - J. F. Angle
- Division of Interventional Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - A. W. Park
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
| | - A. H. Matsumoto
- Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA
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13
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Kilic D, Akin S, Findikcioglu A, Bilen A, Aribogan A, Hatipoglu A. Low-molecular-weight heparin for treatment of submassive pulmonary embolism after pneumonectomy. Gen Thorac Cardiovasc Surg 2007; 55:287-9. [PMID: 17679257 DOI: 10.1007/s11748-007-0124-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pulmonary embolism (PE) after lung resection has a high mortality rate, and it is one of the most severe complications after lung resection. Early diagnosis and treatment are essential. We present a case of severe PE after left pneumonectomy for lung cancer. Computed tomography angiography was useful for confirming the diagnosis of PE. Low-molecular-weight heparin (LMWH) was used to treat the embolism, and the patient was discharged on the seventh day. LMWH is an effective and safe agent for the treatment of PE after pneumonectomy and may reduce the need for surgery. It may be used as an initial procedure. Secondary severe complications, including hemorrhage and subsequent empyema, may be avoided with the use of LMWH.
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Affiliation(s)
- Dalokay Kilic
- Department of Thoracic Surgery, Baskent University Faculty of Medicine, Ankara Teaching and Medical Research Center, 16. Sokak No: 11, Kat 1, 06490 Bahcelievler, Ankara, Turkey.
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14
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Abstract
Until recently, perioperative thrombolysis has always been thought to be a contraindication, because of the risk of bleeding complications. However, many case reports now show that thrombolytic drugs can be successfully used in the perioperative period. Possible indications for perioperative thrombolysis are massive pulmonary embolism and cardiopulmonary resuscitation which are also important causes of cardiac arrest. Thrombolysis can be the decisive therapeutical option, e.g. when normal cardiopulmonary resuscitation measures are not successful. Nevertheless, even against the background of many positive case reports the indication for perioperative thrombolysis should be a case-specific decision as the frequency of complications depends on the surgical intervention and must be weighed against the possible benefits of early thrombolysis. For perioperative thrombolysis there are no data available showing a beneficial effect of one particular therapeutic regimen. In the literature it is suggested that thrombolysis should be performed as quickly as possible, because the risk of bleeding complications depends more on the duration of thrombolysis than on the dosage or the thrombolytic drug itself.
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Affiliation(s)
- F Spöhr
- Klinik für Anaesthesiologie, Universitätsklinikum, Heidelberg.
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15
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Streptokinase and Heparin versus Heparin Alone in Massive Pulmonary Embolism: A Randomized Controlled Trial. J Thromb Thrombolysis 1999; 2:227-229. [PMID: 10608028 DOI: 10.1007/bf01062714] [Citation(s) in RCA: 246] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
To test the efficacy of thrombolytic therapy in massive pulmonary embolism, we conducted a prospective randomized controlled trial. Eight patients were randomized to receive either 1,500,000 IU of streptokinase in 1 hour through a peripheral vein followed by heparin or heparin alone. All patients had major risk factors for deep vein thrombosis (DVT) and were considered to have high clinical suspicion for pulmonary embolism (PE). At baseline all patients had a similar degree of systemic arterial hypotension, pulmonary arterial hypertension, and right ventricular dysfunction. The time of onset of cardiogenic shock in both groups was comparable (2.25 +/- 0.5 hours in the streptokinase group and 1.75 +/- 0.96 hours in the heparin group). The four patients who were randomized to streptokinase improved in the first hour after treatment, survived, and in 2 years of follow-up are without pulmonary arterial hypertension. All four patients treated with heparin alone died from 1 to 3 hours after arrival at the emergency room (p = 0.02). Post-thrombolytic therapy the diagnosis of PE was sustained in the streptokinase group by high probability V/Q lung scans and proven DVT. A necropsy study performed in three patients in the heparin group showed massive pulmonary embolism and right ventricular myocardial infarction, without significant coronary arterial obstruction. The results indicate that thrombolytic therapy reduces the mortality rate of massive acute pulmonary embolism.
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Abstract
We report the successful use of thrombolysis for acute massive pulmonary embolism 2 days after right lower lobectomy for bronchial adenocarcinoma. Pulmonary angiography revealed extensive clot unsuitable for surgical embolectomy. A bolus infusion of recombinant tissue plasminogen activator produced an immediate improvement in the patient's hemodynamic state. There was substantial blood loss requiring the transfusion of 21 units of blood over the postoperative period. The patient made a successful recovery and remained well at 1 year.
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Affiliation(s)
- R A Sayeed
- Cardiothoracic Surgical Unit, Papworth Hospital, Cambridge, United Kingdom
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Wald DS. Perceived contraindications to thrombolytic treatment in acute myocardial infarction. A survey at a teaching hospital. J Accid Emerg Med 1998; 15:329-31. [PMID: 9785162 PMCID: PMC1343175 DOI: 10.1136/emj.15.5.329] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To examine the use of thrombolytic treatment in acute myocardial infarction when faced with perceived contraindications to treatment and to explore the justification for withholding treatment in such clinical situations. METHODS Interview survey of all doctors responsible administering thrombolysis to patients with acute myocardial infarction at a teaching hospital in the UK from March to May 1997. RESULTS 20 doctors were interviewed and asked whether they would give or withhold thrombolysis in a series of 19 clinical situations. These included patients presenting with both an acute myocardial infarction and one of the following associated conditions: a confirmed gastrointestinal haemorrhage, a suspected gastrointestinal haemorrhage, a peptic ulcer, an abdominal aortic aneurysm, a recent cerebrovascular accident, a known intracranial aneurysm, a known intracranial tumour, a recent dental extraction, recent surgery, severe hypertension, proliferative diabetic retinopathy, a history of bleeding diathesis, coma, recent cardiopulmonary resuscitation, pregnancy, menstruation, and a recent central venous puncture. In all but one of the clinical situations (definite current gastrointestinal haemorrhage) there was wide variation in response as to what constitutes a contraindication to thrombolytic treatment. Overall, a substantial proportion of doctors (35%-95%) would withhold treatment on account of any one of these clinical histories. CONCLUSION Clinicians may be withholding thrombolysis in acute myocardial infarction on account of perceived contraindications for which there is little or no evidence of increased haemorrhagic risk. An effective treatment for acute myocardial infarction is probably being underused.
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Ledrick D, Khalil H, Tita J, Mahajan V. Sudden appearance of a mass on chest X-ray. Postgrad Med J 1998; 74:245-6. [PMID: 9683984 PMCID: PMC2360856 DOI: 10.1136/pgmj.74.870.245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- D Ledrick
- University of Pittsburgh Medical Center, PA, USA
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Gopalakrishnan D, Tioran T, Emanuel C, Clark VL. Diffuse pulmonary hemorrhage complicating thrombolytic therapy for acute myocardial infarction. Clin Cardiol 1997; 20:298-300. [PMID: 9068920 PMCID: PMC6656082 DOI: 10.1002/clc.4960200321] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/1996] [Accepted: 03/01/1996] [Indexed: 02/03/2023] Open
Abstract
Diffuse pulmonary hemorrhage has rarely been reported as a complication of thrombolytic therapy. Recently, two patients who developed this complication were observed at our institution. This diagnosis should be considered in any post-thrombolytic patient with respiratory distress, diffuse pulmonary infiltrates, and an otherwise unexplained fall in hemoglobin.
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Affiliation(s)
- D Gopalakrishnan
- Department of Internal Medicine, Henry Ford Hospital, Detroit, Michigan 48202, USA
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Grekos ZG, Schocken DD. Bilateral vitreous hemorrhages as a consequence of thrombolytic therapy successfully treated with vitrectomy in a patient without diabetes. Am Heart J 1995; 130:611-2. [PMID: 7661080 DOI: 10.1016/0002-8703(95)90371-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Z G Grekos
- Department of Internal Medicine, University of South Florida College of Medicine, Tampa 33612, USA
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Lustig LR, Cusick BC, Cheung SW, Lee KC. Lemierre's Syndrome: Two Cases of Postanginal Sepsis. Otolaryngol Head Neck Surg 1995; 112:767-72. [PMID: 7777368 DOI: 10.1016/s0194-59989570192-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Lemierre's disease consists of suppurative thrombophlebitis of the IJV in the presence of oropharyngeal infection and can be complicated by septic pulmonary emboli. If a patient has an oropharyngeal or deep neck infection and neck pain suspicious for IJV thrombosis, a CT or MRI is warranted to establish the diagnosis. Blood cultures should be obtained to establish the responsible organism. In most cases F. necrophorum, an anaerobic bacterium, is responsible for the sepsis. Once the diagnosis of Lemierre's disease is made, long-term, high-dose intravenous antibiotics with beta-lactamase anaerobic activity should be initiated. In cases with persistent sepsis and emboli despite appropriate medical management, ligation or excision of the IJV should be performed. Finally, if there is clinical or radiologic evidence of retrograde cavernous sinus thrombosis, the use of anticoagulants should be considered.
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Affiliation(s)
- L R Lustig
- Department of Otolaryngology-Head and Neck Surgery, University of California, USA
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Affiliation(s)
- E E Weinmann
- Department of Surgery, Beth Israel Hospital, Boston, MA 02215
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Awadh N, Ronco JJ, Bernstein V, Gilks B, Wilcox P. Spontaneous pulmonary hemorrhage after thrombolytic therapy for acute myocardial infarction. Chest 1994; 106:1622-4. [PMID: 7956438 DOI: 10.1378/chest.106.5.1622] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
We report a case of 63-year-old man who developed massive pulmonary hemorrhage following intravenous streptokinase for acute myocardial infarction. Pulmonary hemorrhage was diagnosed by the triad of hemoptysis, a drop in hematocrit, and a new unilateral infiltrate on chest radiograph. This diagnosis was confirmed by autopsy findings. Pulmonary hemorrhage has rarely been reported following thrombolytic therapy. We believe that pulmonary hemorrhage is a rare but a potentially life-threatening complication of thrombolytic therapy and should be considered in the differential diagnosis of pulmonary infiltrates or falling hemoglobin after thrombolytic therapy for acute myocardial infarction with no obvious site of bleeding.
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Affiliation(s)
- N Awadh
- Department of Medicine, University Hospital, Vancouver, Canada
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Reperfusion in acute myocardial infarction. International Society and Federation of Cardiology and World Health Organization Task Force on Myocardial Reperfusion. Circulation 1994; 90:2091-102. [PMID: 7923697 DOI: 10.1161/01.cir.90.4.2091] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Harrington RA, Sane DC, Califf RM, Sigmon KN, Abbottsmith CW, Candela RJ, Lee KL, Topol EJ. Clinical importance of thrombocytopenia occurring in the hospital phase after administration of thrombolytic therapy for acute myocardial infarction. The Thrombolysis and Angioplasty in Myocardial Infarction Study Group. J Am Coll Cardiol 1994; 23:891-8. [PMID: 8106694 DOI: 10.1016/0735-1097(94)90634-3] [Citation(s) in RCA: 54] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES The purpose of this study was to examine the incidence and clinical implications of thrombocytopenia that occurs in hospital after administration of thrombolytic therapy for acute myocardial infarction. BACKGROUND The use of thrombolytic therapy in patients with acute myocardial infarction has improved mortaltiy rates, but hemorrhage remains a major complication. Because thrombocytopenia may be associated with hemorrhage after thrombolytic therapy, we examined the incidence and clinical implications of thrombocytopenia after administration of thrombolytic therapy for acute myocardial infarction. METHODS The patient population comprised 1,001 patients enrolled in Phases 2, 3 and 5 of the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) trial and the urokinase trial. Patients received recombinant tissue-type plasminogen activator, urokinase or combination therapy in various dosing schemes. All patients received heparin, aspirin and a calcium-channel blocking agent. Thrombocytopenia occurring anytime after thrombolytic therapy was defined as a nadir platelet count either < 100,000/microliters or < 1/2 baseline. Blood loss was quantified by a bleeding index. Multiple logistic regression was used to evaluate the independent contribution of thrombocytopenia in a model predicting in-hospital mortality. RESULTS Thrombocytopenia occurred in 16.4% of patients, with no difference among the thrombolytic regimens. Patients with thrombocytopenia had a lower median acute ejection fraction and a higher likelihood of three-vessel coronary artery disease than patients without thrombocytopenia. Patients with thrombocytopenia had more hemorrhage, a higher in-hospital mortality rate and a more complicated hospital course than patients without thrombocytopenia, even after consideration of other important variables, including age, acute ejection fraction, number of diseased vessels, bypass surgery and use of intraaortic balloon counterpulsation. CONCLUSIONS Thrombocytopenia after thrombolytic therapy is a common event and is associated with excess hemorrhage and mortality. Platelet counts should be monitored daily after administration of thrombolytic therapy because the appearance of thrombocytopenia identifies a subset of patients at increased risk for hemorrhage and death.
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Affiliation(s)
- R A Harrington
- Division of Cardiology, Duke University Medical Center, Durham, NC
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Dunn SM, Senerchia CB. Bleeding Complications in the Patient with Cardiac Disease Following Thrombolytic and Anticoagulant Therapies. Crit Care Nurs Clin North Am 1993. [DOI: 10.1016/s0899-5885(18)30555-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sugarman J, Powe NR, Guerci AD, Levine DM. Facts and fears regarding blood transfusions in decision making for thrombolytic therapy. Am Heart J 1993; 126:494-499. [PMID: 8338034 DOI: 10.1016/0002-8703(93)91084-r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
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Girard P, Baldeyrou P, Le Guillou JL, Lamer C, Grunenwald D. Thrombolysis for life-threatening pulmonary embolism 2 days after lung resection. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1993; 147:1595-7. [PMID: 8503574 DOI: 10.1164/ajrccm/147.6_pt_1.1595] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Early postoperative severe pulmonary embolism is usually considered an indication for surgical embolectomy because thrombolytic agents cannot be used. Severe pulmonary embolism was diagnosed 2 days after lung resection in two patients, including one with hypercapnia during spontaneous breathing, perhaps a unique feature of massive embolism on a single lung. Although emergency surgical embolectomy was available, both patients were given a bolus infusion of thrombolytic agents, with an immediate (within 1 h) clinical and hemodynamic improvement and a favorable outcome despite delayed major bleeding in one patient. The reported data and an analysis of the available literature support the view that recent surgery should be considered a relative rather than absolute contraindication to thrombolysis and that decision making in this setting should be based on a careful case-by-case evaluation of the expected benefits and risks of the various available treatments.
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Affiliation(s)
- P Girard
- Department of Thoracic Surgery, Centre Médico-Chirurgical de la Porte de Choisy, Paris, France
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