Anticoagulants vs thrombolytic therapy for the management of right heart thrombus in pulmonary embolism: A systematic review

Table 1 Characteristics of studies included in the analysis

Ref.	Chartier et al[23]	Torbicki et al[14]	Pierre-Justin and Pierard[15]	Seghda et al[7]	Bikdeli et al[18]
Design	Retrospective analysis of a hospital registry	Subgroup analysis of the ICOPER international prospective registry	Prospective single-center study	Prospective cohort study	Analysis of data from the international prospective RIETE registry
Country/center	France (Dijon/Lille)	Multicenter (52 centers, 7 countries)	Martinique (France), Fort-de-France	Burkina Faso, Ouagadougou	Multicenter (international)
Inclusion period	January 1986-January 1998 January	1995-November 1996 November	1997-June 1999	March 2012-September 2015	March 2001-September 2019
Total patients with PE (n)	341 (for the period 1992–1997)	2454	335	250	42620
RHT (n)	38, 28 from 1992 to 1997	42 of 1135 in whom echocardiography was performed	12	11	443 of 18803 in whom echocardiography was performed. Post hoc analysis n = 124
Prevalence of RHT	8.2% (28/341) in 1992-1997	3.7% (42/1135)	4.0% (12/335)	4% (11/250)	2.4% (443/18803)
RHT morphology	Worm-like (36/38), spherical (2/38)	Not described	Mobile: 9 (75%)-coil, 3 (25%)-ball	Mobile thrombi. Specific shape not described	Not described
Location of RHT	RA-30, RV-6, both chambers-2	RA/RV	All-RA (free-floating, could prolapse into RV)	RA in all cases (100%)	Right heart chambers
PE severity	Severe: NYHA IV-84% (32/38), cardiogenic shock-53% (20/38), cardiac arrest-47% (18/38)	More severe course than without RHT: More frequent hypotension, tachycardia, RV dysfunction, and heart failure	Massive PE: All in ICU, syncope (100%), hypotension (mean SBP 96 mmHg), acute pulmonary heart disease in all	All-high/intermediate-high risk	In those who received reperfusion therapy-more frequent hypotension (SBP < 100 mmHg), tachycardia (HR ≥ 110/minutes), syncope, hypoxemia, and RV hypokinesis
Anticoagulant monotherapy (1st line) (n)	8	17	5 (including 3 with absolute contraindications to thrombolysis)	5	62 (post hoc analysis)
Mortality with anticoagulant monotherapy (as first-line treatment)	In-hospital: 5/8 (62.5%)	14-day: 4/17 (23.5%); 3-month: 5/17 (29.4%)	In-hospital: 3/5 (60%)-all with contraindications to thrombolysis	30-day: 4/5 (80%)	30-day post hoc analysis-7/62 (11.3%)
Thrombolysis (1st line) (n)	9	24	7	6	62 (post hoc analysis)
Mortality with thrombolysis (as first-line treatment)	2/9 (22.2%)	14-day: 5/24 (20.8%); 3-month: 7/24 (29.2%)	1/7 (14.3%)	30-day: 1/6 (16.7%)	30-day post hoc analysis-6/62 (9.7%)
Confirmed thrombus lysis	Echocardiographic monitoring was used, but data on the frequency of thrombus lysis are not presented	Not described	In 7 of 9 patients (77.8%) who received thrombolysis, complete thrombus lysis and resolution of RV overload were documented on echocardiography at 12 hours	In all 6 patients who received thrombolysis, complete thrombus lysis was documented on follow-up echocardiography	Not described
Major bleeding	Not described	Not described	None reported	2/11 (18.2%) in the RHT group	Absolute values not provided in the article. Post hoc analysis: 6/62 (9.7%). Reperfusion: 4/62 (6.5%)
Recurrent PE	Not observed during the follow-up period	Not described	0% during hospitalization and 1-year follow-up in survivors	Not described	Not described
Early mortality (14-day/in-hospital)	17/38 (44.7%)	9/42 (21.4%)	4/12 (33.3%)
30-day mortality			4/12 (33.3%)	5/11 (45.4%)	40/443 (9.0%), in post hoc analysis-13/124 (10.5%)
Follow-up period	Mean 47.2 months (range 1-70 months)	3 months	12 months	30 days	30 days
Mortality during the follow-up period	20/38 (52.6%). Among the discharged: 3/21 (14.2%)	12/42 (28.6%)	4/12 (33.3%), among the discharged: 0%	5/11 (45.4%)	40/443 (9.0%) from PE: 24/443 (5.4%)
Authors’ key conclusion on treatment	No significant difference in mortality between methods. Thrombolysis is recommended as a rapid and accessible first-line therapy, especially in the absence of contraindications. Surgery remains the classic method, and catheter-based techniques are an alternative when contraindications exist	Patients with RA/RV thrombi have a higher risk of death, especially if treated with heparin alone. The authors suggest that anticoagulation alone may be insufficient even in clinically stable patients, and more aggressive methods (thrombolysis, embolectomy) should be considered, although this requires further research	Thrombolysis is an effective, rapid, and safe first-line therapy for patients with mobile thrombi. Heparin alone (monotherapy) in severe forms is ineffective and leads to 100% mortality. Surgery is a rescue method when thrombolysis fails	Thrombolysis significantly reduced mortality in the group with thrombi. In the absence of thrombolysis, 30-day survival was < 25%. Thrombolysis is the preferred option when surgical or percutaneous embolectomy is not available	Reperfusion therapy (predominantly thrombolysis) in patients with acute PE and concomitant RHT did not demonstrate a statistically significant reduction in 30-day mortality compared with anticoagulant monotherapy; however, the point estimate of effect (OR = 0.65 for PE-related death) does not rule out clinically meaningful benefit, and the wider confidence intervals indicate the need for further research

ACT: Anticoagulant therapy; ICU: Intensive care unit; OR: Odds ratio; RV: Right ventricle; RA: Right atrium; SBP: Systolic blood pressure; HF: Heart failure; TLT: Thrombolytic therapy; RHT: Right heart thrombi; PE: Pulmonary embolism; HR: Heart rate; EchoCG: Echocardiography; ICOPER: International Cooperative Pulmonary Embolism Registry; NYHA: New York Heart Association; RIETE: Registro Informatizado de Enfermedad Trombo Embólica.