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Bahreini Z, Kamali M, Kheshty F, Bazrafshan Drissi H, Boogar SS, Bazrafshan M. Differentiating electrocardiographic indications of massive and submassive pulmonary embolism: A cross-sectional study in Southern Iran from 2015 to 2020. Clin Cardiol 2024; 47:e24252. [PMID: 38465696 PMCID: PMC10926280 DOI: 10.1002/clc.24252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/16/2024] [Accepted: 02/21/2024] [Indexed: 03/12/2024] Open
Abstract
BACKGROUND Although using electrocardiogram (ECG) for pulmonary embolism (PE) risk stratification has shown mixed results, it is currently used as supplementary evidence in risk stratification. This cross-sectional study aimed to assess and compare ECG findings of massive and submassive PE versus segmental PE. METHODS This cross-sectional study included 250 hospitalized patients with a confirmed diagnosis of acute PE from 2015 to 2020 in Southern Iran. Demographic variables, clinical data, troponin levels, on-admission ECG findings, echocardiography findings, and ECG findings 24 h after receiving anticoagulants or thrombolytics were extracted. RESULTS Patients diagnosed with submassive or massive PE exhibited significantly higher rates of right axis deviation (p = .010), abnormal ST segment (p < .0001), S1Q3T3 pattern (p < .0001), inverted T wave in leads V1-V3 (p < .0001), inverted T wave in leads V4-V6 (p < .0001), and inverted T wave in leads V1-V6 (p < .0001). In a multivariable model, inverted T wave in leads V1-V3, inverted T wave in leads V4-V6, pulse rate, and positive troponin test were the statistically independent variables for predicting submassive or massive PE. Furthermore, inverted T wave in leads V1-V3 (sensitivity: 85%, specificity: 95%, accuracy: 93%, AUC: 0.902) and troponin levels (sensitivity: 72%, specificity: 86%, accuracy: 83%, AUC: 0.792) demonstrated the best diagnostic test performance for discriminating submassive or massive PE from segmental PE. CONCLUSION In addition to clinical rules, ECG can serve as an ancillary tool for assessing more invasive testing and earlier aggressive treatments among patients with PE, as it can provide valuable information for the diagnosis and risk stratification of submassive or massive PE.
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Affiliation(s)
- Zahra Bahreini
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Maliheh Kamali
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | - Fatemeh Kheshty
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
| | | | | | - Mehdi Bazrafshan
- Cardiovascular Research CenterShiraz University of Medical SciencesShirazIran
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Fejes R, Szűcsborus T, Czombos A, Góg C, Ruzsa Z. Managing Patients With Concurrent High Risk for Bleeding and Thromboembolic Events. Cureus 2024; 16:e53557. [PMID: 38445160 PMCID: PMC10913840 DOI: 10.7759/cureus.53557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 03/07/2024] Open
Abstract
The number of patients with high bleeding risk (HBR) and high thromboembolic risk (HTR) is increasing. Gastrointestinal bleeding (GIH), acute coronary syndrome (ACS), and pulmonary embolism (PE) are representative conditions due to HBR/HTR. Although these disorders are located at opposite ends of the same disease spectrum, this does not mean a patient with HBR cannot have a concomitant HTR. The clinical manifestation of these two risks mostly results in critically ill patients for whom management means a huge challenge. We have numerous well-structured guidelines about treating GIH, ACS, or PE, but the literature and recommendations about the concomitant onset of these diseases are limited. Expert recommendations suggest an integrative, comprehensive assessment of patient and intervention-related factors to decide on the antithrombotic regimen with the best clinical benefit by assessing thrombotic and bleeding risks. In general, if thrombotic factors predominate, a longer duration, more aggressive antithrombotic regimen should be planned, and if bleeding susceptibility is higher, a shorter duration, de-escalated regimen should be pursued. In this study, we aimed to explore the clinical dilemmas involved by presenting two cases with delicate management.
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Affiliation(s)
- Roland Fejes
- Department of Internal Medicine, Healthcare Centre of Hódmezővásárhely-Makó, Makó, HUN
| | - Tamás Szűcsborus
- Division of Invasive Cardiology, University of Szeged, Szeged, HUN
| | - András Czombos
- Department of Internal Medicine, Healthcare Centre of Hódmezővásárhely-Makó, Makó, HUN
| | - Csaba Góg
- Department of Internal Medicine, Healthcare Centre of Hódmezővásárhely-Makó, Makó, HUN
| | - Zoltán Ruzsa
- Division of Invasive Cardiology, University of Szeged, Szeged, HUN
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Kobayashi T, Pugliese S, Sethi SS, Parikh SA, Goldberg J, Alkhafan F, Vitarello C, Rosenfield K, Lookstein R, Keeling B, Klein A, Gibson CM, Glassmoyer L, Khandhar S, Secemsky E, Giri J. Contemporary Management and Outcomes of Patients With High-Risk Pulmonary Embolism. J Am Coll Cardiol 2024; 83:35-43. [PMID: 38171708 DOI: 10.1016/j.jacc.2023.10.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Contemporary care patterns/outcomes in high-risk pulmonary embolism (PE) patients are unknown. OBJECTIVES This study sought to characterize the management of high-risk PE patients and identify factors associated with poor outcomes. METHODS A retrospective analysis of the PERT (Pulmonary Embolism Response Team) Consortium Registry was performed. Patients presenting with intermediate-risk PE, high-risk PE, and catastrophic PE (those with hemodynamic collapse) were identified. Patient characteristics were compared with chi-square testing for categorical covariates and Student's t-test for continuous covariates. Multivariable logistic regression was used to assess associations between clinical characteristics and outcomes in the high-risk population. RESULTS Of 5,790 registry patients, 2,976 presented with intermediate-risk PE and 1,442 with high-risk PE. High-risk PE patients were more frequently treated with advanced therapies than intermediate-risk PE patients (41.9% vs 30.2%; P < 0.001). In-hospital mortality (20.6% vs 3.7%; P < 0.001) and major bleeding (10.5% vs. 3.5%; P < 0.001) were more common in high-risk PE. Multivariable regression analysis demonstrated vasopressor use (OR: 4.56; 95% CI: 3.27-6.38; P < 0.01), extracorporeal membrane oxygenation use (OR: 2.86; 95% CI: 1.12-7.30; P = 0.03), identified clot-in-transit (OR: 2.26; 95% CI: 1.13-4.52; P = 0.02), and malignancy (OR: = 1.70; 95% CI: 1.13-2.56; P = 0.01) as factors associated with in-hospital mortality. Catastrophic PE patients (n = 197 [13.7% of high-risk PE patients]) had higher in-hospital mortality (42.1% vs 17.2%; P < 0.001) than those presenting with noncatastrophic high-risk PE. Extracorporeal membrane oxygenation (13.3% vs. 4.8% P < 0.001) and systemic thrombolysis (25% vs 11.3%; P < 0.001) were used more commonly in catastrophic PE. CONCLUSIONS In the largest analysis of high-risk PE patients to date, mortality rates were high with the worst outcomes among patients with hemodynamic collapse.
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Affiliation(s)
- Taisei Kobayashi
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA
| | - Steven Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sanjum S Sethi
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Sahil A Parikh
- Center for Interventional Cardiovascular Care, Columbia University Irving Medical Center, New York, New York, USA
| | - Joshua Goldberg
- Cardiothoracic Surgery Division, Westchester Medical Center, Westchester, New York, USA
| | - Fahad Alkhafan
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Clara Vitarello
- Boston Clinical Research Institute, Boston, Massachusetts, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Robert Lookstein
- Department of Radiology, Mount Sinai Medical Center, New York, New York, USA
| | - Brent Keeling
- Division of Cardiothoracic Surgery, Emory University Hospital, Atlanta, Georgia, USA
| | | | - C Michael Gibson
- Boston Clinical Research Institute, Boston, Massachusetts, USA; Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren Glassmoyer
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sameer Khandhar
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Secemsky
- Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jay Giri
- Cardiovascular Medicine Division, Perelman School of Medicine. University of Pennsylvania, Philadelphia, Pennsylvania, USA; Penn Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania, USA.
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Bermudez M, Pedraza L, Guevara N, Erazo G, Valerio FR. Management of a Right Heart Intracavitary Thrombus in Transit in a Patient With Gastric Cancer in a Resource-Limited Setting: A Case Report. Cureus 2023; 15:e43133. [PMID: 37692570 PMCID: PMC10484470 DOI: 10.7759/cureus.43133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 08/08/2023] [Indexed: 09/12/2023] Open
Abstract
A right atrial thrombus is an unusual source of imminent massive saddle pulmonary embolism (PE) . A hypercoagulable state secondary to gastric cancer (GC) can result in deep vein thrombosis (DVT) with a resultant right-sided heart thrombus in transit. Here, we present a case of a young male patient from Honduras with DVT and multiple venous thrombi extending from the external iliac veins to the suprahepatic left vein, inferior vena cava, and right atrium of the heart, secondary to a hypercoagulable state from GC, adenocarcinoma type. We describe the approach of treating a right heart intracavitary thrombus with imminent risk for saddle PE and sudden cardiac death with thrombolysis through a central venous catheter (CVC) in a resource-limited setting.
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Affiliation(s)
- Marco Bermudez
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Laura Pedraza
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Nehemias Guevara
- Internal Medicine, St. Barnabas Hospital (SBH) Health System, Bronx, USA
| | - Gloria Erazo
- Internal Medicine, Universidad Católica de Honduras, San Pedro Sula, HND
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Pietrasik A, Kurzyna P, Szwed P, Jasińska-Gniadzik K, Gąsecka A, Darocha S, Zieliński D, Szarpak Ł, Kochman J, Grabowski M, Opolski G, Torbicki A, Kurzyna M. Treatment of high- and intermediate- high-risk pulmonary embolism by the Pulmonary Embolism Response Team: Focus on catheter-directed therapies. Cardiol J 2023; 31:215-225. [PMID: 37519055 DOI: 10.5603/cj.a2023.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Multidisciplinary Pulmonary Embolism Response Teams (PERTs) were established to individualize the treatment of high-risk (HR) and intermediate-high-risk (IHR) pulmonary embolism (PE) patients, which pose a challenge in clinical practice. METHODS We retrospectively collected the data of all HR and IHR acute PE patients consulted by PERT CELZAT between September 2017 and October 2022. The patient population was divided into four different treatment methods: anticoagulation alone (AC), systemic thrombolysis (ST), surgical embolectomy (SE), and catheter-directed therapies (CDTx). Baseline clinical characteristics, risk stratification, PE severity parameters, and treatment outcomes were compared between the four groups. RESULTS Of the 110 patients with HR and IHR PE, 67 (61%) patients were treated with AC only, 11 (10%) with ST, 15 (14%) underwent SE, and 17 (15%) were treated with CTDx. The most common treatment option in the HR group was reperfusion therapy, used in 20/24 (83%) cases, including ST in 7 (29%) patients, SE in 5 (21%) patients, and CTDx in 8 (33%) patients. In contrast, IHR patients were treated with AC alone in 63/86 (73%) cases. The in-hospital mortality rate was 9/24 (37.5%) in the HR group and 4/86 (4.7%) in the IHR group. CONCLUSIONS The number of advanced procedures aimed at reperfusion was substantially higher in the HR group than in the IHR PE group. Despite the common use of advanced reperfusion techniques in the HR group, patient mortality remained high. There is a need further to optimize the treatment of patients with HR PE to improve outcomes.
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Affiliation(s)
- Arkadiusz Pietrasik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Paweł Kurzyna
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland.
| | - Piotr Szwed
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
| | | | - Aleksandra Gąsecka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Szymona Darocha
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
| | | | - Łukasz Szarpak
- Henry JN Taub Department of Emergency Medicine, Baylor College of Medicine Houston, Houston, TX, United States
- Institute of Outcomes Research, Maria Sklodowska-Curie Medical Academy, Warsaw, Poland
| | - Janusz Kochman
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Grzegorz Opolski
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Poland
| | - Adam Torbicki
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
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6
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Polaková E, Veselka J. Management of Massive Pulmonary Embolism. Int J Angiol 2022; 31:194-197. [PMID: 36157097 PMCID: PMC9507601 DOI: 10.1055/s-0042-1756176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Pulmonary embolism is a potentially lethal manifestation of venous thromboembolic disease. It is one of the three main causes of cardiovascular morbidity and mortality in developed countries. Over the years, better diagnostic and risk stratification measures were implemented. A generous range of new treatment options is becoming available, particularly for management of massive pulmonary embolism. Nonetheless, clinicians often face uncertainty in clinical practice due to lack of scientific support for available treatment options. The aim of this article is to review management of massive pulmonary embolism.
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Affiliation(s)
- Eva Polaková
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
| | - Josef Veselka
- Department of Cardiology, Second Medical School, Charles University, Motol University Hospital, Prague, Czech Republic
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7
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Assouline B, Assouline-Reinmann M, Giraud R, Levy D, Saura O, Bendjelid K, Combes A, Schmidt M. Management of High-Risk Pulmonary Embolism: What Is the Place of Extracorporeal Membrane Oxygenation? J Clin Med 2022; 11:4734. [PMID: 36012973 DOI: 10.3390/jcm11164734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 08/02/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022] Open
Abstract
Pulmonary embolism (PE) is a common disease with an annual incidence rate ranging from 39–115 per 100,000 inhabitants. It is one of the leading causes of cardiovascular mortality in the USA and Europe. While the clinical presentation and severity may vary, it is a life-threatening condition in its most severe form, defined as high-risk or massive PE. Therapeutic options in high-risk PE are limited. Current guidelines recommend the use of systemic thrombolytic therapy as first-line therapy (Level Ib). However, this treatment has important drawbacks including bleeding complications, limited efficacy in patients with recurrent PE or cardiac arrest, and formal contraindications. In this context, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the management of high-risk PE has increased worldwide in the last decade. Strategies, including VA-ECMO as a stand-alone therapy or as a bridge to alternative reperfusion therapies, are associated with acceptable outcomes, especially if implemented before cardiac arrest. Nonetheless, the level of evidence supporting ECMO and alternative reperfusion therapies is low. The optimal management of high-risk PE patients will remain controversial until the realization of a prospective randomized trial comparing those cited strategies to systemic thrombolysis.
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8
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Dumantepe M, Ozturk C. Acoustic pulse thrombolysis complemented by ECMO improved survival in patients with high-risk pulmonary embolism. J Card Surg 2022; 37:492-500. [PMID: 35020205 DOI: 10.1111/jocs.16222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 09/29/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The optimal treatment of high-risk pulmonary embolism (PE) with cardiac arrest is still controversial although various treatment approaches have been developed and improved. Here, we present a serie of patients with high-risk PE showing hemodynamic collapse, who were successfully treated with extracorporeal membrane oxygenation (ECMO) as an adjunct to EKOS™ acoustic pulse thrombolysis (APT). METHODS From April 2016 to June 2020, 29 patients with high-risk PE with cardiac arrest were retrospectively included. The mean age was 55.3 ± 9.2 years. A total of 12 (41.3%) patients were female. All patients had cardiac arrest, either as an initial presentation or in-hospital after presentation. All patients exhibited acute symptoms, computed tomography evidence of large thrombus burden, and severe right ventricular dysfunction. Primary outcome was all-cause 30-day mortality. RESULTS Twenty-two patients survived to hospital discharge, with a mean intensive care unit stay of 9.9 ± 1.6 days (range: 7-22 days) and mean length of hospital stay of 23.7 ± 8.5 days (range: 11-44 days). Six patients died from refractory shock. Ninety-day mortality was 24.1% (7/29). The Mean ECMO duration was 3.5 ± 1.1 days and the mean RV/LV ratio decreased from 1.31 ± 0.17 to 0.92 ± 0.11 in patients who survived to discharge. The mean tissue plasminogen activator dose for survivor patients was 20.5 ± 1.6 mg. CONCLUSION Patients with high-risk pulmonary embolism who suffer a cardiac arrest have high morbidity and mortality. APT complemented by ECMO could be a successful treatment option for the patients who have high-risk PE with circulatory collapse.
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Affiliation(s)
- Mert Dumantepe
- Department of Cardiovascular Surgery, Uskudar University School of Medicine, Istanbul, Turkey
| | - Cuneyd Ozturk
- Department of Cardiovascular Surgery, Florence Nightingale Hospital, Istanbul, Turkey
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9
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Bishay VL, Adenikinju O, Todd R. FlowTriever Retrieval System for the treatment of pulmonary embolism: overview of its safety and efficacy. Expert Rev Med Devices 2021; 18:1039-1048. [PMID: 34530650 DOI: 10.1080/17434440.2021.1982379] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. There has been little change in PE mortality rates over the past two decades making this an appealing area for innovation and development. AREAS COVERED While anticoagulation (AC) and systemic thrombolysis (ST) are the mainstay treatments for high-risk PE and intermediate-high-risk PE with decompensation, advancements in catheter- based therapies offer potential alternatives. Areas covered here will include present guidelines for PE treatment and the landscape of catheter-directed therapies with a focus on the FlowTriever (FT) Retrieval System. Available safety and efficacy data will be reviewed. An online search via Google Scholar and PubMed with the keywords INARI Flowtriever, venous thromboembolism, and pulmonary embolism, alongside bibliographies of published articles, was undertaken as a review of the literature on the FlowTriever system for this device overview. EXPERT OPINION The five-year outlook on the role of catheter-directed therapies in the management of PE includes continued innovation in catheter-directed therapies and a number of high-quality trials on the horizon.
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Affiliation(s)
- Vivian L Bishay
- Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
| | | | - Rachel Todd
- Icahn School of Medicine, Mount Sinai Health System, New York, NY, USA
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10
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Baldetti L, Beneduce A, Cianfanelli L, Falasconi G, Pannone L, Moroni F, Venuti A, Sacchi S, Gramegna M, Pazzanese V, Calvo F, Gallone G, Pagnesi M, Cappelletti AM. Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism: A systematic review and meta-analysis. Artif Organs 2021; 45:569-576. [PMID: 33277695 DOI: 10.1111/aor.13876] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/27/2020] [Accepted: 11/16/2020] [Indexed: 12/29/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) represents a therapeutic option for cardiopulmonary support in patients with high-risk pulmonary embolism (PE); however, no definite consensus exists on ECMO use in high-risk PE. Hence, we aim to provide insights into its real-world use pooling together all available published experiences. We performed a systematic review and pooled analysis of all published studies (up to April 17, 2020) investigating ECMO support in high-risk PE. All studies including at least four patients were collectively analyzed. Study outcomes were early all-cause death (primary endpoint) and relevant in-hospital adverse events. A total of 21 studies were included in the pooled analysis (n = 635 patients). In this population (mean age 47.8 ± 17.3 years, 44.5% females), ECMO was indicated for cardiac arrest in 62.3% and immediate ECMO support was pursued in 61.9% of patients. Adjunctive reperfusion therapies were implemented in 57.0% of patients. Pooled estimate rate of early all-cause mortality was 41.1% (95% CI 27.7%-54.5%). The most common in-hospital adverse event was major bleeding, with an estimated rate of 28.6% (95%CI 21.0%-36.3%). At meta-regression analyses, no significant impact of multiple covariates on the primary endpoint was found. In this systematic review of patients who received ECMO for high-risk PE, pooled all-cause mortality was 41.1%. Principal indication for ECMO was cardiac arrest, cannulation was chiefly performed at presentation, and major bleeding was the most common complication.
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Affiliation(s)
- Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Beneduce
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Cianfanelli
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Falasconi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Pannone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Moroni
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Angela Venuti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Stefania Sacchi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mario Gramegna
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Vittorio Pazzanese
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Calvo
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Internal Medicine, Città della Salute e della Scienza, Torino, Italy
| | - Matteo Pagnesi
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
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Affiliation(s)
- Samuel Z Goldhaber
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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12
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Bunc M, Steblovnik K, Zorman S, Popovic P. Percutaneous mechanical thrombectomy in patients with high-risk pulmonary embolism and contraindications for thrombolytic therapy. Radiol Oncol 2020; 54:62-7. [PMID: 32061168 DOI: 10.2478/raon-2020-0006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [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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13
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Zhang Y, Ma L, Fu Q, Zhao T, Yan RY, Su X. Comparison of urokinase and reteplase thrombolytic treatment in patients with high-risk pulmonary embolism. Exp Ther Med 2019; 18:4804-4810. [PMID: 31798706 PMCID: PMC6880444 DOI: 10.3892/etm.2019.8153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/10/2019] [Indexed: 12/21/2022] Open
Abstract
Thrombolytic treatment is recommended for patients with high-risk pulmonary embolism. The present study compared thrombolytic therapy with urokinase and reteplase. A total of 37 patients presenting with acute high-risk pulmonary embolism at the Intensive Care Unit of Weinan Central Hospital of Shaanxi Province (Weinan, China) between June 2013 and January 2017 were retrospectively analyzed. According to their treatment, these subjects were assigned to the reteplase group (n=16) or the urokinase group (n=21). Systolic blood pressure (SBP), heart rate (HR) and respiratory rate (RR) were recorded prior to, and at 2, 4, 24 and 48 h after thrombolytic therapy. Complications, including bleeding, were closely monitored. Changes in blood gas analysis, troponin-T (TNT), pro-B-type natriuretic peptide (pro-BNP) and D-dimer (D-D) were observed. In the reteplase and urokinase group, 11 and 13 cases exhibited marked improvement, treatment was rated as effective in 4 and 6 cases, and 1 and 2 mortalities occurred, resulting in an overall effective rate of 93.8 and 90.5%, respectively (P>0.05). In the reteplase group, one patient was unsuccessfully resuscitated and died. In the urokinase group, one patient died of gastric hemorrhage after 22 h of thrombolysis, while another patient died of brain failure resuscitation. The treatment improved the SBP in each of the two groups (P<0.05), and this outcome was similar between these two groups (P>0.05). HR and RR were similar prior to and after thrombolytic therapy (P>0.05). In contrast to the urokinase group, TNT was significantly decreased after thrombolyis compared with the baseline in the reteplase group. Complications in the reteplase group were higher, but in contrast to the urokinase group, no life-threatening bleeding occurred. Although reteplase is as effective as urokinase in treating high-risk pulmonary embolism, reteplase may reduce myocardial damage.
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Affiliation(s)
- Yi Zhang
- Department of Internal Medicine, Weinan Hospital of Traditional Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
| | - Lan Ma
- Department of Intensive Care Unit, Weinan Central Hospital Affiliated to Shaanxi University of Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
| | - Qi Fu
- Department of Pharmacy, Weinan Central Hospital Affiliated to Shaanxi University of Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
| | - Tao Zhao
- Department of Intensive Care Unit, Weinan Central Hospital Affiliated to Shaanxi University of Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
| | - Rui-Ying Yan
- Department of Intensive Care Unit, Weinan Central Hospital Affiliated to Shaanxi University of Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
| | - Xing Su
- Department of Intensive Care Unit, Weinan Central Hospital Affiliated to Shaanxi University of Chinese Medicine, Weinan, Shaanxi 714000, P.R. China
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Porres-Aguilar M, Anaya-Ayala JE, Heresi GA, Rivera-Lebron BN. Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism. Clin Appl Thromb Hemost 2018; 24:48S-55S. [PMID: 30453745 PMCID: PMC6714822 DOI: 10.1177/1076029618812954] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Pulmonary embolism represents the third most common cause of cardiovascular death
in the United States. Reperfusion therapeutic strategies such as systemic
thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and
cardiopulmonary support devices are currently available for patients with high-
and intermediate-high–risk pulmonary embolism. However, deciding on optimal
therapy may be challenging. Pulmonary embolism response teams have been designed
to facilitate multidisciplinary decision-making with the goal to improve quality
of care for complex cases with pulmonary embolism. Herein, we discuss the
current role and strategies on how to leverage the strengths from pulmonary
embolism response teams, its possible worldwide adoption, and implementation to
improve survival and change the paradigm in the care of a potentially deadly
disease.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Hospital Medicine, Department of Internal Medicine, Northcentral Baptist Medical Center, San Antonio, TX, USA
| | - Javier E Anaya-Ayala
- Section of Vascular Surgery and Endovascular Therapy, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, México
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine; University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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15
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Furdyna A, Ciurzyński M, Roik M, Paczyńska M, Wretowski D, Jankowski K, Lipińska A, Bienias P, Kosturbiec M, Łabyk A, Trzebicki J, Palczewski P, Kurnicka K, Lichodziejewska B, Pacho S, Pruszczyk P. Management of high risk pulmonary embolism - a single center experience. Folia Med Cracov 2018; 58:75-83. [PMID: 30745603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND AIM Patients with acute pulmonary embolism (APE) associated with hemodynamic instability, i.e. high-risk APE (HR-APE), are at risk for early mortality and require urgent reperfusion therapy with thrombolysis or embolectomy. However, a considerable proportion of HR-APE subjects is not reperfused but only anticoagulated due to high bleeding risk. The aim of the present study was to assess the management of HR-APE in a single large-volume referral center. METHODS A single-center retrospective study of 32 HR-APE subjects identified among 823 consecutive patients hospitalized for symptomatic APE. RESULTS Out of 32 subjects with HR-APE (19 women, age 69 ± 19 years), 20 patients were unstable at admission and 12 subsequently deteriorated despite on-going anticoagulation. Thrombolysis was applied in 20 (62.5%) of HR-APE subjects, limited mainly by classical contraindications in the remainder. Percutaneous pulmonary embolectomy was performed in 4 patients. In-hospital PE-related mortality tended to be higher, albeit insignificantly, in the patients who developed hemodynamic collapse during the hospital course compared to those unstable at admission (67% vs. 40%, p = 0.14). Also, survival was slightly better in 22 patients treated with thrombolysis or percutaneous embolectomy in comparison to 10 subjects who received only anticoagulation (54% vs. 40%, p = 0.2). Major non-fatal bleedings occurred in 7 of 20 patients receiving thrombolysis (35%) and in 2 (17%) of the remaining non-thrombolysed 12 HR-APE subjects. CONCLUSIONS Hemodynamically instability, corresponding to the definition of HR-APE, affects about 4% of patients with APE, developing during the hospital course in approximately one-third of HR-APE subjects. As almost 40% of patients with HR-APE do not receive thrombolytic therapy for fear of bleeding, urgent percutaneous catheter-assisted embolectomy may increase the percentage of patients with HR-APE undergoing reperfusion therapy. Further studies are warranted for a proper identification of initially stable intermediate-risk APE subjects at risk of hemodynamic collapse despite appropriate anticoagulation.
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Affiliation(s)
- Aleksandra Furdyna
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - Michał Ciurzyński
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marzanna Paczyńska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dominik Wretowski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Jankowski
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Lipińska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Bienias
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Maciej Kosturbiec
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Andrzej Łabyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Janusz Trzebicki
- First Department of Anaesthesiology and Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Palczewski
- Department of Radiology, Medical University of Warsaw, Warsaw, Poland
| | - Katarzyna Kurnicka
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Barbara Lichodziejewska
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Szymon Pacho
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
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16
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Yıldırım F, Özer A. High-risk Pulmonary Embolism: Should We Be Less Patient with Thrombolytic Therapy? Intern Med 2017; 56:3407. [PMID: 29249767 PMCID: PMC5790740 DOI: 10.2169/internalmedicine.8202-16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Fatma Yıldırım
- Department of Pulmonary and Critical Care Medicine, Dışkapı Yıldırım Beyazıt Education and Research Hospital, Turkey
| | - Abdullah Özer
- Department of Cardiovascular Surgery, School of Medicine, Gazi University, Turkey
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