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Rahmani R, Jensen KN, Bhargava D, Paul BW, Huguenard AL, Eberle AT, Fargen KM, Hui FK, Starke RM, Brinjikji W, Arthur AS, Chatterjee AR, Osbun J, Jadhav AP, Levy EI, Siddiqui AH, Pukenas B, Catapano JS, Srinivasan VM, Burkhardt JK. Cerebral venous thrombectomy: the new frontier. J Neurointerv Surg 2025:jnis-2025-023467. [PMID: 40268405 DOI: 10.1136/jnis-2025-023467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2025] [Indexed: 04/25/2025]
Affiliation(s)
- Redi Rahmani
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kate N Jensen
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Daksh Bhargava
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Brian W Paul
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Anna L Huguenard
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adam T Eberle
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Ferdinand K Hui
- Neuroscience Institute, Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami Leonard M Miller School of Medicine, Miami, Florida, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic Minnesota, Rochester, Minnesota, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Josh Osbun
- Department of Neurosurgery, Washington University Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Elad I Levy
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Bryan Pukenas
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jafri M, Stojak B, Mooney O, Macdiarmid A, Gibson IW, Dhaliwal S. Percutaneous vacuum-assisted tumor thrombectomy using angiovac and penumbra lightning 12 aspiration systems. Radiol Case Rep 2025; 20:2194-2202. [PMID: 39990621 PMCID: PMC11847502 DOI: 10.1016/j.radcr.2025.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2024] [Revised: 01/03/2025] [Accepted: 01/15/2025] [Indexed: 02/25/2025] Open
Abstract
A 19-year-old female presented with a 2-month history of abdominal discomfort and palpable abdominal mass; a computer tomography scan revealed a large retroperitoneal mass as well as high suspicion of thrombus in her inferior vena cava. Right kidney core biopsy showed diagnostic features of synovial sarcoma. While awaiting workup for her mass she was placed on anticoagulants. However, she re-presented to hospital 3 weeks later complaining of 3 days of shortness of breath. A repeat computer tomography scan revealed extensive thrombus burden with tumor thrombus involving the inferior vena cava, a large right atrial intracardiac thrombus, multiple segmental right pulmonary emboli, and a large embolus causing total occlusion of the left main pulmonary artery with findings suggestive of associated lung infarction. The patient's disease was not amenable to surgical resection and thrombolytic therapy was contraindicated due to associated intratumor hemorrhage, thus prompting consideration of thrombectomy under emergency approval from Health Canada. The patient underwent an overall successful total aspiration thrombectomy of the intracardiac tumor thrombus with subsequent resolution of her right heart strain, using the extracorporeal AngioVac aspiration system and partial aspiration of the extensive pulmonary emboli using the Penumbra Indigo Lightning 12 system. She was transferred to the intensive care unit and extubated 2 days later and was discharged from hospital shortly after without supplemental oxygen.
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Affiliation(s)
- Murtaza Jafri
- Faculty of Medicine, University of Manitoba, Manitoba, Canada
| | - Brittany Stojak
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Owen Mooney
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrew Macdiarmid
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ian W. Gibson
- Department of Pathology, Associate Professor Pathology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Surinder Dhaliwal
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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Jimenez Tejero E, Lopez-Alcalde J, Correa-Pérez A, Stallings E, Gaetano Gil A, Del Campo Albendea L, Mateos-Haro M, Fernandez-Felix BM, Stallings R, Alvarez-Diaz N, García Laredo E, Solier A, Fernández-Martínez E, Morillo Guerrero R, de Miguel M, Perez R, Antequera A, Muriel A, Jimenez D, Zamora J. Sex as a prognostic factor for mortality in adults with acute symptomatic pulmonary embolism. Cochrane Database Syst Rev 2025; 3:CD013835. [PMID: 40110896 PMCID: PMC12043200 DOI: 10.1002/14651858.cd013835.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/22/2025]
Abstract
BACKGROUND Pulmonary embolism (PE) is relatively common worldwide. It is a serious condition that can be life-threatening. Studies on the relationship between adverse outcomes of this condition and whether a patient is male or female have yielded inconsistent results. Determining whether there is an association between sex and short-term mortality in patients with acute PE is important as this information may help guide different approaches to PE monitoring and treatment. OBJECTIVES To determine whether sex (i.e. being a male or a female patient) is an independent prognostic factor for predicting mortality in adults with acute symptomatic pulmonary embolism. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL databases, and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials register up to 17 February 2023. We scanned conference abstracts and reference lists of included studies and systematic reviews. We also contacted experts to identify additional studies. There were no restrictions with respect to language or date of publication. SELECTION CRITERIA We included phase 2-confirmatory prognostic studies, that is, any longitudinal study (prospective or retrospective) evaluating the independent association between sex (male or female) and mortality in adults with acute PE. DATA COLLECTION AND ANALYSIS We followed the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of prognostic factor studies (CHARMS-PF) and the Cochrane Prognosis Methods Group template for prognosis reviews. Two review authors independently screened the studies, extracted data, assessed the risk of bias according to the Quality in Prognosis Studies (QUIPS) tool, and assessed the certainty of the evidence (GRADE). Meta-analyses were performed by pooling adjusted estimates. When meta-analysis was not possible, we reported the main results narratively. MAIN RESULTS We included seven studies (726,293 participants), all of which were retrospective cohort studies with participants recruited and managed in hospitals between 2000 and 2018. Studies took place in the USA, Spain, and Japan. Most studies were multicentre. None were conducted in low- or middle-income countries. The participants' mean age ranged from 62 to 69 years, and the proportion of females was higher in six of the seven studies, ranging from 46% to 60%. Sex and gender terms were used inconsistently. Participants received different PE treatments: reperfusion, inferior vena cava filter, anticoagulation, and haemodynamic/respiratory support. The prognostication time (the point from which the outcome was predicted) was frequently omitted. The included studies provided data for three of our outcomes of interest. We did not consider any of the studies to be at an overall low risk of bias for any of the outcomes analysed. We judged the certainty of the evidence as moderate to low due to imprecision and risk of bias. We found moderate-certainty evidence (due to imprecision) that for female patients there is likely a small but clinically important reduction in all-cause mortality at 30 days (odds ratio (OR) 0.81, 95% confidence interval (CI) 0.72 to 0.92; I2 = 0%; absolute risk difference (ARD) 24 fewer deaths in women per 1000 participants, 95% CI 35 to 10 fewer; 2 studies, 17,627 participants). However, the remaining review outcomes do not indicate lower mortality in female patients. There is low-certainty evidence (due to serious risk of bias and imprecision) indicating that for females with PE, there may be a small but clinically important increase in all-cause hospital mortality (OR 1.11, 95% CI 1.00 to 1.22; I2 = 21.7%; 95% prediction interval (PI) 0.76 to 1.61; ARD 13 more deaths in women per 1000 participants, 95% CI 0 to 26 more; 3 studies, 611,210 participants). There is also low-certainty evidence (due to very serious imprecision) indicating that there may be little to no difference between males and females in PE-related mortality at 30 days (OR 1.08, 95% CI 0.55 to 2.12; I2 = 0%; ARD 4 more deaths in women per 1000 participants, 95% CI 22 fewer to 50 more; 2 studies, 3524 participants). No study data was found for the other outcomes, including sex-specific mortality data at one year. Moreover, due to insufficient studies, many of our planned methods were not implemented. In particular, we were unable to conduct assessments of heterogeneity or publication bias or subgroup and sensitivity analyses. AUTHORS' CONCLUSIONS The evidence is uncertain about sex (being male or female) as an independent prognostic factor for predicting mortality in adults with PE. We found that, for female patients with PE, there is likely a small but clinically important reduction in all-cause mortality at 30 days relative to male patients. However, this result should be interpreted cautiously, as the remaining review outcomes do not point to an association between being female and having a lower risk of death. In fact, the evidence in the review also suggested that, in female patients, there may be a small but clinically important increase in all-cause hospital mortality. It also showed that there may be little to no difference in PE-related mortality at 30 days between male and female patients. There is currently no study evidence from longitudinal studies for our other review outcomes. Although the available evidence is conflicting and therefore cannot support a recommendation for or against routinely considering sex to quantify prognosis or to guide personalised therapeutic approaches for patients with PE, this Cochrane review offers information to guide future primary research and systematic reviews.
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Affiliation(s)
- Elena Jimenez Tejero
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Cochrane Associate Centre of Madrid, Madrid, Spain
| | - Jesús Lopez-Alcalde
- Faculty of Medicine, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
- Cochrane Associate Centre of Madrid, Madrid, Spain
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Institute for Complementary and Integrative Medicine, University Hospital Zurich; University of Zurich, Zurich, Switzerland
| | - Andrea Correa-Pérez
- Hospital Pharmacy and Medical Devices Department, Hospital Central de la Defensa "Gomez Ulla", Madrid, Spain
| | - Elena Stallings
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Andrea Gaetano Gil
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Laura Del Campo Albendea
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Miriam Mateos-Haro
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | - Borja Manuel Fernandez-Felix
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
| | - Raymond Stallings
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | | | - Eduardo García Laredo
- Faculty of Health Sciences, Universidad Internacional de La Rioja (UNIR), Logroño, Spain
- Comet Global Innovation SL, Barcelona, Spain
| | - Aurora Solier
- Respiratory Department, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
| | | | - Raquel Morillo Guerrero
- Department of Pneumology, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Marcos de Miguel
- Department of Anesthesiology and Intensive Care, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raquel Perez
- Respiratory Department, Hospital Universitario 12 de Octubre, Universidad Complutense Madrid, Madrid, Spain
| | - Alba Antequera
- International Health Department, ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Alfonso Muriel
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
- Department of Nursing and Physiotherapy, Universidad de Alcalá, Alcalá De Henares, Spain
| | - David Jimenez
- Respiratory Department, Hospital Universitario Ramón y Cajal (IRYCIS), Madrid, Spain
- Medicine Department, Universidad de Alcalá (IRYCIS), Madrid, Spain
- CIBER Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Javier Zamora
- Clinical Biostatistics Unit, Hospital Universitario Ramón y Cajal (IRYCIS); CIBER Epidemiology and Public Health (CIBERESP), Madrid, Spain
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Atik S, Ergün R, Ergün D, Narin Çopur E, Kılınçer A, Körez MK. The Role of the Pulmonary Artery Obstruction Index Ratio in Predicting the Clinical Course of Pulmonary Embolism. J Clin Med 2025; 14:1673. [PMID: 40095678 PMCID: PMC11900484 DOI: 10.3390/jcm14051673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2025] [Revised: 02/15/2025] [Accepted: 02/27/2025] [Indexed: 03/19/2025] Open
Abstract
Background/Objective: This study aimed to investigate the relationship between the pulmonary arterial computed tomography obstruction index ratio (CTOI) and the simplified pulmonary embolism severity index (sPESI), one of the clinical probability scoring modalities, in determining the severity of PE and to determine whether CTOI is a mortality marker. Methods: The study included 117 patients diagnosed with PE via computed tomography pulmonary angiography (CTPA). The CTOI was determined according to the localization of the embolus and the obstruction caused by the embolus in the vessel. Patients were divided into two groups, namely low-risk and high-risk groups, according to their sPESI values. Patient deaths up to six months after PE diagnosis were recorded. Results: According to the sPESI classification, although the CTOI was higher in the high-risk group compared to the low-risk group, no significant difference was found between the groups. The mortality rate was significantly higher in the high-risk group. After six months of follow-up, there was no difference in the CTOI rate between the patients who died and those who survived. Conclusions: Although CTPA is the gold standard for diagnosing PE, it would be more appropriate to use it together with clinical findings to determine the severity of the disease. Further evaluation is needed to investigate the usefulness of the obstruction index and CT findings of right ventricular dysfunction for classifying patient risk and determining therapeutic options.
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Affiliation(s)
- Serap Atik
- Department of Pulmonary Medicine, Iğdır Dr. Nevruz Erez State Hospital, Iğdır 76000, Turkey
| | - Recai Ergün
- Department of Pulmonary Medicine, Faculty of Medicine, Selcuk University, Konya 42130, Turkey;
| | - Dilek Ergün
- Department of Pulmonary Medicine, Faculty of Medicine, Selcuk University, Konya 42130, Turkey;
| | - Ecem Narin Çopur
- Department of Pulmonary Medicine, Dr. Yaşar Eryılmaz Doğubeyazıt State Hospital, Ağrı 04402, Turkey;
| | - Abidin Kılınçer
- Department of Radiology, Faculty of Medicine, Selcuk University, Konya 42130, Turkey;
| | - Muslu Kazım Körez
- Department of Biostatistics, Faculty of Medicine, Selcuk University, Konya 42130, Turkey;
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Keller K, Schmidt FP, Farmakis IT, Barco S, Fengler K, Knorr M, Gori T, Münzel T, Lurz P, Hobohm L. Time trends of catheter-directed treatment in acute pulmonary embolism in Germany. Res Pract Thromb Haemost 2025; 9:102651. [PMID: 39834528 PMCID: PMC11743116 DOI: 10.1016/j.rpth.2024.102651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2024] [Revised: 11/27/2024] [Accepted: 12/03/2024] [Indexed: 01/22/2025] Open
Abstract
Background Catheter-directed treatment (CDT) is an innovative treatment for patients with elevated risk pulmonary embolism (PE) to resolve embolus and restore pulmonary perfusion. Objectives We aimed to analyse the use and the benefit of CDT in PE patients in Germany. Methods The German nationwide inpatient sample was used to include all hospitalizations of patients with PE from 2005 to 2020 in Germany. PE patients were stratified for CDT usage. Temporal trends and the impact of CDT on case fatality and other outcomes were investigated. Results Overall, 1,373,084 hospitalizations of patients with PE (55.9% aged ≥70 years; 53.0% females) were included in this study from 2005 to 2020, and among these, 427,238 (31.1%) patients were categorized as having elevated-risk PE and 3330 (0.2%) were treated with CDT with annual increase from 0.17% (2005) to 0.51% (2020). PE patients of younger age, male sex, with previous surgery, and elevated-risk PE were more often treated with CDT. In patients with elevated risk-PE, CDT attributed to a lower observed rate of major adverse cardiac and cerebrovascular events (major adverse cardiac and cerebrovascular events [MACCE]; 28.2% vs 34.2%; P < .001) and in-hospital case fatality (24.9% vs 31.0%; P < .001). CDT was associated with reduced MACCE (OR, 0.91; 95% CI, 0.83-0.99) and with a trend toward lower case fatality (OR, 0.92; 95% CI, 0.84-1.01). The benefit of CDT regarding case fatality was age-dependent. Conclusion Although the annual rate of CDT increased in Germany between 2005 and 2020, only 0.2% of the PE patients were treated with CDT. Selection criteria for CDT treatment were younger age, male sex, previous surgery, and elevated risk-PE. CDT treatment was associated with reduced MACCE and case-fatality rate in PE patients with elevated-risk PE.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Sports Medicine, Medical Clinic VII, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Ioannis T. Farmakis
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Department of Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Karl Fengler
- Department of Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Maike Knorr
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Philipp Lurz
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Mainz, Germany
| | - Lukas Hobohm
- Department of Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Wang G, Liu T, Ji W, Wang N, Sun J, Lv L, Yu X, Cheng X, Li M, Hu T, Shi Z. Prolonged elevated heart rate is association with adverse outcome in severe pulmonary embolism: A retrospective study. Int J Cardiol 2024; 417:132581. [PMID: 39306287 DOI: 10.1016/j.ijcard.2024.132581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 09/05/2024] [Accepted: 09/18/2024] [Indexed: 09/30/2024]
Abstract
BACKGROUND Pulmonary embolism (PE) is a critical condition characterized by the obstruction of pulmonary arteries by thrombi, which significantly contributes to morbidity and mortality globally. Although prolonged elevated heart rate (peHR) is recognized as a risk factor for adverse outcomes in critically ill patients, its specific impact on severe PE has remained unexplored. METHODS This retrospective cohort study analyzed data from the Medical Information Mart for Intensive Care (MIMIC)-IV database. Patients diagnosed with PE were included in the study. peHR was defined as heart rates exceeding 100 beats per minute on at least 11 occasions within any 12-h interval. Cox proportional hazards regression models were used to evaluate the impact of peHR on 30-day and 90-day mortality rates, adjusting for a broad range of demographic and clinical variables. RESULTS A total of 1248 patients were included in this study, of whom 540 exhibited peHR. These patients experienced significantly longer hospital and intensive care unit (ICU) stays, as well as higher mortality rates at both 30 days (25.93 % vs. 14.97 %, P < 0.001) and 90 days (33.89 % vs. 22.74 %, P < 0.001) compared to patients without peHR. Multivariate Cox regression analysis confirmed peHR as an independent predictor of increased mortality at 30 days (HR 1.56, 95 % CI 1.19-2.07; P = 0.0014) and 90 days (HR 1.66, 95 % CI 1.32-2.10; P < 0.001). CONCLUSION peHR significantly worsens outcomes in severe PE patients, underscoring the need for stringent heart rate monitoring and management. These findings advocate for integrating heart rate control within management strategies for severe PE, potentially improving survival outcomes.
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Affiliation(s)
- Guangdong Wang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Tingting Liu
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Wenwen Ji
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Na Wang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Jiaolin Sun
- Department of Respiratory and Critical Care Medicine, Shaanxi Provincial People's Hospital, Xi'an, Shanxi 710068, China
| | - Lin Lv
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Xiaohui Yu
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Xue Cheng
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Mengchong Li
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China
| | - Tinghua Hu
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China.
| | - Zhihong Shi
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi 710061, China.
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Benavente K, Fujiuchi B, Virk HUH, Kavali PK, Ageno W, Barnes GD, Righini M, Alam M, Rosovsky RP, Krittanawong C. A Practical Clinical Approach to Navigate Pulmonary Embolism Management: A Primer and Narrative Review of the Evolving Landscape. J Clin Med 2024; 13:7637. [PMID: 39768560 PMCID: PMC11728314 DOI: 10.3390/jcm13247637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2024] [Revised: 12/08/2024] [Accepted: 12/13/2024] [Indexed: 01/16/2025] Open
Abstract
Advances in imaging, pharmacological, and procedural technologies have rapidly expanded the care of pulmonary embolism. Earlier, more accurate identification and quantification has enhanced risk stratification across the spectrum of the disease process, with a number of clinical tools available to prognosticate outcomes and guide treatment. Direct oral anticoagulants have enabled a consistent and more convenient long-term therapeutic option, with a greater shift toward outpatient treatment for a select group of low-risk patients. The array of catheter-directed therapies now available has contributed to a more versatile and nuanced armamentarium of treatment options, including ultrasound-facilitated thrombolysis and mechanical thrombectomy. Research into supportive care for pulmonary embolism have explored the optimal use of vasopressors and volume resuscitation, as well as utilization of various devices, including right ventricular mechanical support and extracorporeal membrane oxygenation. Even in the realm of surgery, outcomes have steadily improved in experienced centers. This rapid expansion in diagnostic and therapeutic data has necessitated implementation of pulmonary embolism response teams to better interpret the available evidence, manage the utilization of advanced therapies, and coordinate multidisciplinary care. We provide a narrative review of the risk stratification and management of pulmonary embolism, with a focus on structuralizing the multidisciplinary approach and organizing the literature on new and emerging therapies.
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Affiliation(s)
- Kevin Benavente
- Department of Medicine, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI 96813, USA; (K.B.); (B.F.)
| | - Bradley Fujiuchi
- Department of Medicine, John A. Burns School of Medicine, University of Hawai’i, Honolulu, HI 96813, USA; (K.B.); (B.F.)
| | - Hafeez Ul Hassan Virk
- Harrington Heart & Vascular Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, OH 44106, USA;
| | - Pavan K. Kavali
- Interventional Radiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO 63110, USA;
| | - Walter Ageno
- Department of Clinical Medicine, University of Insubria, 21100 Varese, Italy;
| | - Geoffrey D. Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI 48109, USA;
| | - Marc Righini
- Division of Angiology and Hemostasis, Department of Medicine, Geneva University Hospitals and Faculty of Medicine, CH-1211 Geneva, Switzerland;
| | - Mahboob Alam
- The Texas Heart Institute, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Rachel P. Rosovsky
- Division of Hematology & Oncology, Department of Medicine, Massachusetts Hospital, Boston, MA 02114, USA;
| | - Chayakrit Krittanawong
- Section of Cardiology, Cardiology Division, NYU Langone Health and NYU School of Medicine, 550 First Avenue, New York, NY 10016, USA
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Wu S, Jamal F. Cardiooncology in the ICU - Cardiac Urgencies in Cancer Care. J Intensive Care Med 2024:8850666241303461. [PMID: 39632745 DOI: 10.1177/08850666241303461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2024]
Abstract
Cardiovascular disease is an increasing risk of morbidity and mortality in cancer patients, related to an growing number of aging survivors with pre-existing cardiovascular disease and the use of traditional and novel cancer therapies with cardiotoxic effects. While many cardiac complications are chronic processes that develop over time, there are many acute processes that may arise in hospitalized patients. It is important for hospitalists and critical care physicians to be familiar with the recognition and management of these conditions in this unique population. This article reviews the presentation and management of common cardiac urgencies in critically ill cancer patients including acute decompensated heart failure, acute coronary syndromes, arrhythmias, hypertensive crises, pulmonary embolism, pericardial tamponade and myocarditis.
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Affiliation(s)
- Stephanie Wu
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
| | - Faizi Jamal
- Department of Medicine, City of Hope Comprehensive Cancer Center, Duarte, California, USA
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9
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Konstantinides SV, Sanchez O, Goldhaber SZ, Meneveau N. Advancing the management of acute intermediate-high-risk pulmonary embolism: The enduring legacy of Professor Guy Meyer. Presse Med 2024; 53:104248. [PMID: 39244019 DOI: 10.1016/j.lpm.2024.104248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2024] [Accepted: 09/03/2024] [Indexed: 09/09/2024] Open
Abstract
Only few years after the first report on diagnosing acute pulmonary embolism (PE) with pulmonary angiography, studies began to investigate the effectiveness and safety of thrombolytic therapy for achieving early reperfusion. In 1992, Guy Meyer demonstrated the fast improvement of pulmonary haemodynamics after alteplase administration; this drug has remained the mainstay of thrombolysis for PE over almost 35 years. In the meantime, algorithms for PE risk stratification continued to evolve. The landmark Pulmonary Embolism International Thrombolysis (PEITHO) trial, led by Guy Meyer, demonstrated the clinical efficacy of thrombolysis for intermediate-risk PE, albeit at a relatively high risk of major, particularly intracranial bleeding. Today, systemic thrombolysis plays an only minor role in the real-world treatment of acute PE in the United States and Europe, but major trials are underway to test safer reperfusion regimens. Of those, the PEITHO-3 study, conceived by Guy Meyer and other European and North American experts, is an ongoing randomised, placebo-controlled, double-blind, multinational academic trial. The primary objective is to assess the efficacy of reduced-dose intravenous thrombolytic therapy against the background of heparin anticoagulation in patients with intermediate-high-risk PE. In parallel, trials with similar design are testing the efficacy and safety of catheter-directed local thrombolysis or mechanical thrombectomy. Increasingly, focus is being placed on long-term functional and patient-reported outcomes, including quality of life indicators, as well as on the utilization of health care resources. The pioneering work of Guy Meyer will thus continue to have a major impact on the management of PE for years to come.
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Affiliation(s)
- Stavros V Konstantinides
- Center for Thrombosis and Heamostasis, University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Greece.
| | - Olivier Sanchez
- Université Paris Cité; Service de Pneumologie et Soins Intensifs, Hôpital Européen Georges Pompidou, AP-HP; INSERM UMRS 1140, Paris, France; FCRIN INNOVTE, St-Etienne, France
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Nicolas Meneveau
- SINERGIES, University of Franche-Comté, Besançon, France; Department of Cardiology, University Hospital Besançon, Besançon, France
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10
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Davies MG, Hart JP. Extracorporal Membrane Oxygenation in Massive Pulmonary Embolism. Ann Vasc Surg 2024; 105:287-306. [PMID: 38588954 DOI: 10.1016/j.avsg.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Massive pulmonary embolism (MPE) carries significant 30-day mortality risk, and a change in societal guidelines has promoted the increasing use of extracorporeal membrane oxygenation (ECMO) in the immediate management of MPE-associated cardiovascular shock. This narrative review examines the current status of ECMO in MPE. METHODS A literature review was performed from 1982 to 2022 searching for the terms "Pulmonary embolism" and "ECMO," and the search was refined by examining those publications that covered MPE. RESULTS In the patient with MPE, veno-arterial ECMO is now recommended as a bridge to interventional therapy. It can reliably decrease right ventricular overload, improve RV function, and allow hemodynamic stability and restoration of tissue oxygenation. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Applying ECMO is also associated with substantial multisystem morbidity due to systemic inflammatory response, bleeding with coagulopathy, hemorrhagic stroke, renal dysfunction, and acute limb ischemia, which must be factored into the outcomes. CONCLUSIONS The application of ECMO in MPE should be combined with an aggressive interventional pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX; Department of Vascular and Endovascular Surgery, Ascension Health, Waco, TX.
| | - Joseph P Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI
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11
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Scott EJ, Young S, Ratcliffe SJ, Wang XQ, Mehaffey JH, Sharma A, Rycus P, Tonna J, Yarboro L, Bryner B, Collins M, Teman NR. Venoarterial Extracorporeal Life Support Use in Acute Pulmonary Embolism Shows Favorable Outcomes. Ann Thorac Surg 2024; 118:253-260. [PMID: 38360341 DOI: 10.1016/j.athoracsur.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 01/04/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
BACKGROUND Differences in outcomes by indication for venoarterial extracorporeal life support (VA-ECLS) are poorly described. We hypothesized that patients on VA-ECLS for acute pulmonary embolism (PE) have fewer complications and better survival than patients on VA-ECLS for other indications. METHODS All patients ≥18 years on VA-ECLS from the Extracorporeal Life Support Organization global registry (2010-2019) were evaluated (n = 29,842). After excluding patients aged >79 years (n = 729) and those with incomplete indication data (n = 2530), patients were stratified by VA-ECLS indication for PE vs all other indications. The association between being discharged alive and each type of complication with VA-ECLS indication was assessed. RESULTS Of 26,583 patients included in the analysis, 978 (3.7%) were on VA-ECLS for a primary diagnosis of acute PE. Acute PE patients were younger (53.1 vs 56.7 years, P < .001) and were more likely to be women (52.1% vs 32.3%, P < .001). Patients who underwent VA-ECLS for acute PE were 78% more likely to be discharged alive vs patients supported with VA-ECLS for other reasons (52.8% vs 40.4%; P < .001). Acute PE patients had fewer cardiovascular and renal complications (26.6% vs 38.0% and 31.1% vs 39.4%, respectively; adjusted P < .001). Acute PE patients had higher odds of having clots and mechanical complications (8.7% vs 7.9% and 16.7% vs 14.6%, respectively; adjusted P < .001). CONCLUSIONS Patients undergoing VA-ECLS for acute PE have higher odds of survival to hospital discharge compared with those supported for other indications. Additionally, VA-ECLS in this population is associated with fewer cardiovascular and renal complications but higher mechanical complications.
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Affiliation(s)
- Erik J Scott
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Steven Young
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Sarah J Ratcliffe
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - Xin-Qun Wang
- Division of Biostatistics, Department of Public Health Sciences, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Aditya Sharma
- Division of Vascular Medicine, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Joseph Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Leora Yarboro
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Ben Bryner
- Division of Cardiovascular Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Michael Collins
- Department of Thoracic and Cardiovascular Surgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Nicholas R Teman
- Division of Cardiac Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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12
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Chopard R, Morillo R, Meneveau N, Jiménez D. Integration of Extracorporeal Membrane Oxygenation into the Management of High-Risk Pulmonary Embolism: An Overview of Current Evidence. Hamostaseologie 2024; 44:182-192. [PMID: 38531394 DOI: 10.1055/a-2215-9003] [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: 03/28/2024] Open
Abstract
High-risk pulmonary embolism (PE) refers to a large embolic burden causing right ventricular failure and hemodynamic instability. It accounts for approximately 5% of all cases of PE but contributes significantly to overall PE mortality. Systemic thrombolysis is the first-line revascularization therapy in high-risk PE. Surgical embolectomy or catheter-directed therapy is recommended in patients with an absolute contraindication to systemic thrombolysis. Extracorporeal membrane oxygenation (ECMO) provides respiratory and hemodynamic support for the most critically ill PE patients with refractory cardiogenic shock or cardiac arrest. The complex management of these individuals requires urgent yet coordinated multidisciplinary care. In light of existing evidence regarding the utility of ECMO in the management of high-risk PE patients, a number of possible indications for ECMO utilization have been suggested in the literature. Specifically, in patients with refractory cardiac arrest, resuscitated cardiac arrest, or refractory shock, including in cases of failed thrombolysis, venoarterial ECMO (VA-ECMO) should be considered, either as a bridge to percutaneous or surgical embolectomy or as a bridge to recovery after surgical embolectomy. We review here the current evidence on the use of ECMO as part of the management strategy for the highest-risk presentations of PE and summarize the latest data in this indication.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - Raquel Morillo
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, Besançon, France
- SINERGIES, University of Franche-Comté, Besançon, France
- F-CRIN, INNOVTE network, France
| | - David Jiménez
- Respiratory Department, Hospital Ramón y Cajal and Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Medicine Department, Universidad de Alcalá, (IRYCIS) Madrid, Spain
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13
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Ellauzi R, Erdem S, Salam MF, Kumar A, Aggarwal V, Koenig G, Aronow HD, Basir MB. Mechanical Circulatory Support Devices in Patients with High-Risk Pulmonary Embolism. J Clin Med 2024; 13:3161. [PMID: 38892871 PMCID: PMC11172824 DOI: 10.3390/jcm13113161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/22/2024] [Accepted: 05/08/2024] [Indexed: 06/21/2024] Open
Abstract
Pulmonary embolism (PE) is a common acute cardiovascular condition. Within this review, we discuss the incidence, pathophysiology, and treatment options for patients with high-risk and massive pulmonary embolisms. In particular, we focus on the role of mechanical circulatory support devices and their possible therapeutic benefits in patients who are unresponsive to standard therapeutic options. Moreover, attention is given to device selection criteria, weaning protocols, and complication mitigation strategies. Finally, we underscore the necessity for more comprehensive studies to corroborate the benefits and safety of MCS devices in PE management.
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Affiliation(s)
- Rama Ellauzi
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI 48202, USA
| | - Saliha Erdem
- Department of Internal Medicine, Detroit Medical Center, Wayne State University, Detroit, MI 48202, USA;
| | - Mohammad Fahad Salam
- Department of Internal Medicine, Michigan State University, East Lansing, MI 48502, USA;
| | - Ashish Kumar
- Department of Internal Medicine, Cleveland Clinic Akron General, Akron, OH 44307, USA;
| | - Vikas Aggarwal
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Gerald Koenig
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Herbert D. Aronow
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
| | - Mir Babar Basir
- Department of Cardiovascular Medicine, Henry Ford Hospital, Detroit, MI 48202, USA; (V.A.); (H.D.A.)
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14
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Cardona S, Downing JV, Witting MD, Haase DJ, Powell EK, Dahi S, Pasrija C, Tran QK. Venoarterial Extracorporeal Membrane Oxygenation With or Without Advanced Intervention for Massive Pulmonary Embolism. Perfusion 2024; 39:665-674. [PMID: 37246150 DOI: 10.1177/02676591231177909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Massive pulmonary embolism (MPE) is a rare but highly fatal condition. Our study's objective was to evaluate the association between advanced interventions and survival among patients with MPE treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO). METHODS This is a retrospective review of the Extracorporeal Life Support Organization (ELSO) registry data. We included adult patients with MPE who were treated with VA-ECMO during 2010-2020. Our Primary outcome was survival to hospital discharge; secondary outcomes were ECMO duration among survivors and rates of ECMO-related complications. Clinical variables were compared using the Pearson chi-square and Kruskal-Wallis H tests. RESULTS We included 802 patients; 80 (10%) received SPE and 18 (2%) received CDT. Overall, 426 (53%) survived to discharge; survival was not significantly different among those treated with SPE or CDT on VA-ECMO (70%) versus VA-ECMO alone (52%) or SPE or CDT before VA-ECMO (52%). Multivariable regression found a trend towards increased survival among those treated with SPE or CDT while on ECMO (AOR 1.8, 95% CI 0.9-3.6), but no significant correlation. There was no association between advanced interventions and ECMO duration among survivors, or rates of ECMO-related complications. CONCLUSION Our study found no difference in survival in patients with MPE who received advanced interventions prior to ECMO, and a slight non-significant benefit in those who received advanced interventions while on ECMO.
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Affiliation(s)
- Stephanie Cardona
- Department of Critical Care Medicine, The Mount Sinai Hospital, New York, NY, USA
| | - Jessica V Downing
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael D Witting
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel J Haase
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Elizabeth K Powell
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Quincy K Tran
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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15
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Melamed R, Tierney DM, Xia R, Brown CS, Mara KC, Lillyblad M, Sidebottom A, Wiley BM, Khapov I, Gajic O. Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study. Crit Care Med 2024; 52:729-742. [PMID: 38165776 DOI: 10.1097/ccm.0000000000006162] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2024]
Abstract
OBJECTIVES Systemic thrombolysis improves outcomes in patients with pulmonary embolism (PE) but is associated with the risk of hemorrhage. The data on efficacy and safety of reduced-dose alteplase are limited. The study objective was to compare the characteristics, outcomes, and complications of patients with PE treated with full- or reduced-dose alteplase regimens. DESIGN Multicenter retrospective observational study. SETTING Tertiary care hospital and 15 community and academic centers of a large healthcare system. PATIENTS Hospitalized patients with PE treated with systemic alteplase. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Pre- and post-alteplase hemodynamic and respiratory variables, patient outcomes, and complications were compared. Propensity score (PS) weighting was used to adjust for imbalances of baseline characteristics between reduced- and full-dose patients. Separate analyses were performed using the unweighted and weighted cohorts. Ninety-eight patients were treated with full-dose (100 mg) and 186 with reduced-dose (50 mg) regimens. Following alteplase, significant improvements in shock index, blood pressure, heart rate, respiratory rate, and supplemental oxygen requirements were observed in both groups. Hemorrhagic complications were lower with the reduced-dose compared with the full-dose regimen (13% vs. 24.5%, p = 0.014), and most were minor. Major extracranial hemorrhage occurred in 1.1% versus 6.1%, respectively ( p = 0.022). Complications were associated with supratherapeutic levels of heparin anticoagulation in 37.5% of cases and invasive procedures in 31.3% of cases. The differences in complications persisted after PS weighting (15.4% vs. 24.7%, p = 0.12 and 1.3% vs. 7.1%, p = 0.067), but did not reach statistical significance. There were no significant differences in mortality, discharge destination, ICU or hospital length of stay, or readmission after PS weighting. CONCLUSIONS In a retrospective, PS-weighted observational study, when compared with the full-dose, reduced-dose alteplase results in similar outcomes but fewer hemorrhagic complications. Avoidance of excessive levels of anticoagulation or invasive procedures should be considered to further reduce complications.
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Affiliation(s)
- Roman Melamed
- Department of Critical Care, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - David M Tierney
- Department of Graduate Medical Education, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
- Department of Medicine, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Ranran Xia
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Caitlin S Brown
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Kristin C Mara
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Matthew Lillyblad
- Department of Pharmacy, Abbott Northwestern Hospital, Allina Health, Minneapolis, MN
| | - Abbey Sidebottom
- Department of Care Delivery Research, Allina Health, Minneapolis, MN
| | - Brandon M Wiley
- Department of Medicine, Los Angeles General Medical Center, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ivan Khapov
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Ognjen Gajic
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
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16
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Mehrban A, Hajikolaei FA, Karimi M, Khademi R, Ansari A, Qujeq D, Hajian-Tilaki K, Monadi M. Evaluation of elevated serum apelin-13 and D-dimer concentrations in individuals diagnosed with pulmonary embolism. Int J Emerg Med 2024; 17:48. [PMID: 38565984 PMCID: PMC10986010 DOI: 10.1186/s12245-024-00619-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 03/17/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Given the limited specificity of D-dimer, there is a perceived need to discover a more precise marker for diagnosing individuals who are suspected of having pulmonary embolism (PE). In this study, by evaluating the increase in the serum level of Apelin-13 and D-dimer, we found valuable findings about Apelin-13, which can be suggested as an auxiliary and non-invasive diagnostic biomarker in individuals with suspected PE, based on the obtained results. METHODS In this case-control study, 52 Iranian individuals were included, all of whom were suspected to have PE. These individuals were then divided into two groups based on the results of CT angiography, which is considered the gold standard imaging method for diagnosing PE. The two groups were patients with PE and patients without PE. Finally, the levels of certain markers in the serum were compared between the two groups. RESULTS The mean serum D-dimer levels in patients with PE were significantly elevated (p < 0.001) in comparison to those without PE (1102.47 to 456.2 ng/ml). Furthermore, the mean level of Apelin-13 was significantly higher in patients with PE (49.8 to 73.11 ng/L) (p < 0.001). The cutoff point of Apelin-13 has been calculated at 58.50 ng/ml, with 90.9% sensitivity and 90% specificity. The D-dimer cutoff point was 500 ng/ml, with 95.5% sensitivity and 43.3% specificity. CONCLUSIONS Based on the results of this study, the serum level of Apelin-13 can be used as a novel diagnostic and screening biomarker in patients with pulmonary thromboembolism.
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Affiliation(s)
- Alireza Mehrban
- Shariati Hospital, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | | | - Mehdi Karimi
- Bogomolets National Medical University (NMU), Kyiv, Ukraine.
| | - Reza Khademi
- Student Research Committee, Faculty of Medicine, Mashhad University of Medical (MUMS) , Mashhad, Iran
| | - Akram Ansari
- Shantou University Medical College, Shantou, Guangdong, China
| | - Durdi Qujeq
- Department of Clinical Biochemistry, Babol University of Medical Sciences (MUBabol), Babol, Iran
| | - Karimollah Hajian-Tilaki
- Department of Social Medicine, Faculty of Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran
| | - Mahmood Monadi
- Department of Internal Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran.
- School of Medicine, Babol University of Medical Sciences (MUBabol), Babol, Iran.
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17
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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] [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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18
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Millington SJ, Aissaoui N, Bowcock E, Brodie D, Burns KEA, Douflé G, Haddad F, Lahm T, Piazza G, Sanchez O, Savale L, Vieillard-Baron A. High and intermediate risk pulmonary embolism in the ICU. Intensive Care Med 2024; 50:195-208. [PMID: 38112771 DOI: 10.1007/s00134-023-07275-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/11/2023] [Indexed: 12/21/2023]
Abstract
Pulmonary embolism (PE) is a common and important medical emergency, encountered by clinicians across all acute care specialties. PE is a relatively uncommon cause of direct admission to the intensive care unit (ICU), but these patients are at high risk of death. More commonly, patients admitted to ICU develop PE as a complication of an unrelated acute illness. This paper reviews the epidemiology, diagnosis, risk stratification, and particularly the management of PE from a critical care perspective. Issues around prevention, anticoagulation, fibrinolysis, catheter-based techniques, surgical embolectomy, and extracorporeal support are discussed.
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Affiliation(s)
- Scott J Millington
- Critical Care, The University of Ottawa/The Ottawa Hospital, Ottawa, ON, Canada
| | - Nadia Aissaoui
- Service de Médecine Intensive-Réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP). Centre & Université Paris Cité, Paris, France
| | - Emma Bowcock
- Department of Intensive Care, Nepean Hospital, University of Sydney, Sydney, Australia
| | - Daniel Brodie
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karine E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Li Ka Shing Knowledge Institute, Unity Health Toronto-St. Michael's Hospital, Toronto, Canada
| | - Ghislaine Douflé
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Canada
| | - François Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Stanford Cardiovascular Institute, Stanford University, Stanford, CA, USA
- Vera Moulton Wall Center for Pulmonary Vascular Disease at Stanford University, Stanford, CA, USA
| | - Tim Lahm
- Pulmonary Sciences and Critical Care Medicine, National Jewish Health, University of Colorado, Rocky Mountain Regional VA Medical Center, Denver, CO, USA
| | - Gregory Piazza
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Olivier Sanchez
- Service de pneumologie et soins intensifs, Hopital Européen Georges Pompidou, APHP, Paris, France
- INSERM UMR S 1140, Innovative Therapies in Hemostasis, Université Paris Cité, Paris, France
| | - Laurent Savale
- Department of Respiratory and Intensive Care Medicine, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
- INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Antoine Vieillard-Baron
- Medical and Surgical ICU, University Hospital Ambroise Pare, GHU Paris-Saclay, APHP, Boulogne-Billancourt, France.
- Inserm U1018, CESP, Universite Versailles Saint-Quentin en Yvelines, Guyancourt, France.
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Tajeri T, Langroudi TF, Zadeh AH, Taherkhani M, Arjmand G, Abrishami A. The correlation between the CT angiographic pulmonary artery obstructive index and clinical data in patients with acute pulmonary thromboembolism. Emerg Radiol 2024; 31:45-51. [PMID: 38102455 DOI: 10.1007/s10140-023-02187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023]
Abstract
PURPOSE The potentially fatal consequences of pulmonary embolism emphasize the need for more effective diagnostic methods. The Qanadli obstruction index has been described as a convenient tool for risk stratification to determine and quantify the degree of obstruction. This study aimed to assess the correlations between the Qanadli index with clinical and paraclinical findings (D-dimer, troponin, and echocardiographic findings) in patients with pulmonary embolism. MATERIALS AND METHODS A total of 102 patients with pulmonary embolism underwent echocardiography and CT pulmonary angiography at a single tertiary referral center between 2019 and 2020. The clinical and paraclinical findings, pulmonary arterial obstruction index, atrial measurements, right and left ventricle size and function, tricuspid annular plane systolic excursion, pulmonary artery pressure, and pulmonary hypertension (PH) were analyzed. Vital signs were recorded and assessed. The Qanadli index score was measured, and graded risk stratification was measured based on the quantified index score. RESULTS The total mean Qanadli index was 28.75 ± 23.75, and there was no significant relationship between the Qanadli index and gender. Patients' most common clinical findings were exertional dyspnea (84.3%; n = 86) and chest pain (71.7%; n = 73). There were significant correlations between the Qanadli index and pulse rate (PR), troponin, D-dimer levels, and PH. Four patients died during the study, including one from a cardiac condition and three with non-cardiac conditions. CONCLUSIONS It is possible to determine the severity, prognosis, and appropriate treatment by the Qanadli index based on strong correlations with PR, troponin, D-dimer levels, and PH.
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Affiliation(s)
- Taraneh Tajeri
- Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taraneh Faghihi Langroudi
- Radiology Department, Shahid Modarres Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arezou Hashem Zadeh
- Student's Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Taherkhani
- Cardiovascular Research Center, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, 9Th Boostan St, Tehran, 1419733141, Iran.
| | - Ghazal Arjmand
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Abrishami
- Department of Radiology, Shahid Labbafinejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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20
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Dönmez E, Özcan S, Sahin İ, Ziyrek M, Okuyan E. Can GRACE Risk Score Predict Mortality and the Need for Thrombolytic Treatment in Acute Pulmonary Embolism? Am J Cardiol 2024; 211:115-121. [PMID: 37923156 DOI: 10.1016/j.amjcard.2023.10.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/29/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
Acute coronary syndrome and pulmonary embolism (PE) are clinical entities sharing similar presentation and risk factors. Risk scores and indexes help to identify disease severity in both diseases. In this study, we aimed to evaluate if the Global Registry of Acute Coronary Events (GRACE) risk score could predict 30-day mortality and the need for thrombolytic treatment in patients with acute PE. Patients hospitalized with a diagnosis of PE in our tertiary center between January 2018 and May 2022 were included in this retrospective study. Pulmonary Embolism Severity Index (PESI) and GRACE risk scores on admission were calculated using clinical, electrocardiographic, and laboratory parameters for each patient. A total of 197 patients were included. The 30-day mortality rate was 28.4% whereas 32.5% of the patients required thrombolytic treatment. GRACE and PESI scores were found independent risk factors associated with 30-day mortality and the need for thrombolytic treatment. A cut-off value of 160.5 for GRACE score was associated with 88.5% sensitivity and 89.4% specificity in prediction of 30-day mortality. In contrast, GRACE score had 61.0% sensitivity and 60.0% specificity in the prediction of the need for thrombolytic treatment when the cut-off value was 147. In conclusion, GRACE risk score has an effective discriminating power in determining the early mortality of patients with acute PE. The incidence of short-term PE-related mortality was significantly increased in patients with high GRACE risk scores. Concomitant use of GRACE and PESI risk scores may aid in defining patients with high-risk PE and help predict poor prognosis with high specificity and probability.
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Affiliation(s)
- Esra Dönmez
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Sevgi Özcan
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey.
| | - İrfan Sahin
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Murat Ziyrek
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
| | - Ertugrul Okuyan
- Department of Cardiology, Bağcılar Training and Research Hospital, Bağcılar, İstanbul, Turkey
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21
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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: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [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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22
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Mohamad T, Kanaan E, Ogieuhi IJ, Mannaparambil AS, Ray R, Al-Nazer LWM, Ahmed HM, Hussain M, Kumar N, Kumari K, Nadeem M, Kumari S, Varrassi G. Thrombolysis vs Anticoagulation: Unveiling the Trade-Offs in Massive Pulmonary Embolism. Cureus 2024; 16:e52675. [PMID: 38380194 PMCID: PMC10877223 DOI: 10.7759/cureus.52675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
Massive pulmonary embolism (MPE) is a severe form of venous thromboembolism (VTE) wherein enormous blood clots block the pulmonary arteries, resulting in substantial illness and death. Even with the progress made in diagnostic methods and treatments, the most effective approach for managing MPE is still a topic of considerable discussion. This study examines the delicate equilibrium between thrombolysis and anticoagulation in managing the problematic clinical situation posed by MPE, elucidating the compromises linked to each strategy. The genesis of MPE lies in the pathophysiology of VTE, when blood clots that originate from deep veins in the lower legs or pelvis move to the pulmonary vasculature, leading to an abrupt blockage. This obstruction leads to a series of hemodynamic alterations, such as elevated pulmonary vascular resistance, strain on the right ventricle, and compromised cardiac output, finally resulting in cardiovascular collapse. The seriousness of MPE is commonly categorized according to hemodynamic stability, with significant cases presenting immediate risks to patient survival. Traditionally, heparin has been the primary approach to managing MPE to prevent the spread of blood clots and their movement to other parts of the body. Nevertheless, there have been ongoing discussions regarding the effectiveness of thrombolysis, which entails the immediate delivery of fibrinolytic drugs to remove the blood clot. The use of thrombolysis in managing MPE is being reconsidered because of concerns over bleeding complications and long-term results despite its capacity to resolve the blocking clot quickly. This review rigorously analyzes the current body of evidence, exploring the intricacies of thrombolysis and anticoagulation in MPE. The focus is on evaluating the risk-benefit balance of each treatment option, considering aspects such as the patient's other medical conditions, hemodynamic stability, and potential long-term consequences. This review aims to clarify the complexities of the thrombolysis versus anticoagulation dilemma. It seeks to provide clinicians, researchers, and policymakers with a thorough understanding of the trade-offs in managing MPE. The goal is to facilitate informed decision-making and enhance patient outcomes.
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Affiliation(s)
- Tamam Mohamad
- Cardiovascular Medicine, Wayne State University, Detroit, USA
| | - Eyas Kanaan
- Internal Medicine, Corewell Health, Grand Rapids, USA
| | - Ikponmwosa J Ogieuhi
- Physiology, University of Benin, Benin City, NGA
- General Medicine, Siberian State Medical University, Tomsk, RUS
| | | | - Rubela Ray
- Internal Medicine, Bankura Sammilani Medical College and Hospital, Bankura, IND
| | | | | | | | | | - Komal Kumari
- Medicine, NMC Royal Family Medical Centre, Abu Dhabi, ARE
| | | | - Sanvi Kumari
- Internal Medicine, Jinnah Sindh Medical University, Karachi, PAK
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Davies MG, Hart JP. Current status of ECMO for massive pulmonary embolism. Front Cardiovasc Med 2023; 10:1298686. [PMID: 38179509 PMCID: PMC10764581 DOI: 10.3389/fcvm.2023.1298686] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
Massive pulmonary embolism (MPE) carries significant 30-day mortality and is characterized by acute right ventricular failure, hypotension, and hypoxia, leading to cardiovascular collapse and cardiac arrest. Given the continued high mortality associated with MPE, there has been ongoing interest in utilizing extracorporeal membrane oxygenation (ECMO) to provide oxygenation support to improve hypoxia and offload the right ventricular (RV) pressure in the belief that rapid reduction of hypoxia and RV pressure will improve outcomes. Two modalities can be employed: Veno-arterial-ECMO is a reliable process to decrease RV overload and improve RV function, thus allowing for hemodynamic stability and restoration of tissue oxygenation. Veno-venous ECMO can support oxygenation but is not designed to help circulation. Several societal guidelines now suggest using ECMO in MPE with interventional therapy. There are three strategies for ECMO utilization in MPE: bridge to definitive interventional therapy, sole therapy, and recovery after interventional treatment. The use of ECMO in MPE has been associated with lower mortality in registry reviews, but there has been no significant difference in outcomes between patients treated with and without ECMO in meta-analyses. Considerable heterogeneity in studies is a significant weakness of the available literature. Applying ECMO is also associated with substantial multisystem morbidity due to a systemic inflammatory response, hemorrhagic stroke, renal dysfunction, and bleeding, which must be factored into the outcomes. The application of ECMO in MPE should be combined with an aggressive pulmonary interventional program and should strictly adhere to the current selection criteria.
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Affiliation(s)
- Mark G. Davies
- Center for Quality, Effectiveness, and Outcomes in Cardiovascular Diseases, Houston, TX, United States
- Department of Vascular/Endovascular Surgery, Ascension Health, Waco, TX, United States
| | - Joseph P. Hart
- Division of Vascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
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24
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Iannaccone M, Franchin L, Russo F, Botti G, Castellano D, Montorfano M, Boccuzzi G, Mamas MA, Chieffo A. Mortality across treatment strategies in intermediate-to-high risk pulmonary embolism in the modern era: A meta-analysis of observational studies and RCTs. Int J Cardiol 2023; 387:131127. [PMID: 37355238 DOI: 10.1016/j.ijcard.2023.131127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/26/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) represents one of the leading causes of death worldwide and mainly treated with medical management, although the utility of more invasive approaches has emerged more recently. This meta-analysis aims to evaluate the 30-day mortality of intermediate-to-high risk PE across different treatment strategies. METHODS A systematic literature review and meta-analysis was conducted using PubMed and Cochrane databases. All studies reporting 30-day mortality rates in intermediate-to-high-risk PE were included. Meta-regression analysis and sensitivity analysis were performed on the primary endpoint, 30-day mortality, and secondary endpoints (RV/LV ratio, mPAP, and long-term mortality, any bleeding events). RESULTS Of the 2390 studies published between 2000 and 2022, 76 studies (74 observational and 2 RCTs for a total of 1,194,285 patients in the medical cohort and 3007 in the interventional cohort) were included. The median age was 71.4 (IQR 62.8-77.3) years, 53.6% were women. 30-day mortality in the patients treated with medical management was 9.1% (6.6-12.6). In the interventional cohort, 30-day mortality was 2.1% (1.5-3.1) while the pre- vs post-procedure change in mean difference was -6.1 mmHg (-11.2 to -1.1) for mPAP and - 0.41 (-0.51 to - 0.31) for RV/LV ratio. The overall bleeding rate in the interventional cohort was 4.9% (CI 2.6-8.9), without differences between the two strategies (RR 1.26 CI 0.89-1.78). CONCLUSION Intermediate-high-risk mortality in pulmonary embolisms treated with medical management remains high in the modern era. Despite the absence of comparative studies, an interventional approach may have a lower 30-day mortality rate and a good safety profile.
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Affiliation(s)
- Mario Iannaccone
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy.
| | - Luca Franchin
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy; Department of Cardiology, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Filippo Russo
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulia Botti
- IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Davide Castellano
- Division of Radiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Matteo Montorfano
- IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo Boccuzzi
- Division of Cardiology, San Giovanni Bosco Hospital, ASL Città di Torino, Turin, Italy
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke on Trent, UK
| | - Alaide Chieffo
- IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
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25
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Aykan AÇ, Gökdeniz T, Gül İ, Kalaycıoğlu E, Karabay CY, Boyacı F, Hatem E, Weingart SD, Dursun İ. Reduced-Dose Systemic Fibrinolysis in Massive Pulmonary Embolism: A Pilot Study. Clin Exp Emerg Med 2023; 10:280-286. [PMID: 37188358 PMCID: PMC10579734 DOI: 10.15441/ceem.23.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/17/2023] Open
Abstract
OBJECTIVE Severe pulmonary embolism (PE) has a high mortality rate, which can be lowered by thrombolytic therapy (TT). However, full-dose TT is associated with major complications, including life-threatening bleeding. The aim of this study was to explore the efficacy and safety of extended, low-dose administration of tissue plasminogen activator (tPA) on in-hospital mortality and outcomes in massive PE. METHODS This was a single-center, prospective cohort trial at a tertiary university hospital. A total of 37 consecutive patients with massive PE were included. A peripheral intravenous infusion was used to administer 25 mg of tPA over 6 hours. The primary endpoints were in-hospital mortality, major complications, pulmonary hypertension, and right ventricular dysfunction. The secondary endpoints were 6-month mortality and pulmonary hypertension and right ventricular dysfunction 6 months after the PE. RESULTS The mean age of the patients was 68.76±14.54 years. The mean pulmonary artery systolic pressure (PASP; 56.51±7.34 mmHg vs. 34.16±2.81 mmHg, P<0.001) and right/left ventricle diameter (1.37±0.12 vs. 0.99±0.12, P<0.001) decreased significantly after TT. Tricuspid annular plane systolic excursion (1.43±0.33 cm vs. 2.07±0.27 cm, P<0.001), myocardial performance index (0.47±0.08 vs. 0.55±0.07, P<0.001), and systolic wave prime (9.6±2.8 vs. 15.3±2.6) increased significantly after TT. No major bleeding or stroke was observed. There was one in-hospital death and two additional deaths within 6 months. No cases of pulmonary hypertension were identified during follow-up. CONCLUSION The results of this pilot study suggest that an extended infusion of low-dose tPA is a safe and effective therapy in patients with massive PE. This protocol was also effective in decreasing PASP and restoring right ventricular function.
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Affiliation(s)
- Ahmet Çağrı Aykan
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
- Department Cardiology, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras, Turkey
| | - Tayyar Gökdeniz
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - İlker Gül
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Ezgi Kalaycıoğlu
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Can Yücel Karabay
- Department of Cardiology, University of Health Sciences Doktor Siyami Ersek Education and Research Hospital, Istanbul, Turkey
| | - Faruk Boyacı
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Engin Hatem
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
| | - Scott D. Weingart
- Division of Emergency Critical Care, Nassau University Medical Center, East Meadow, NY, USA
| | - İhsan Dursun
- Department of Cardiology, University of Health Sciences Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital, Trabzon, Turkey
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26
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Shah S, Ogbonna AV, Nance J, Gregoski MJ, Tedford R, Ramu B, Todoran TM, Litwin SE. A Multimodality Imaging Approach to Defining Risk in Patients With Acute Pulmonary Embolism. J Am Soc Echocardiogr 2023; 36:933-940. [PMID: 37178724 DOI: 10.1016/j.echo.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/22/2023] [Accepted: 05/04/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Morbidity and mortality for acute pulmonary embolism (PE) remain high. Therapies such as catheter-directed thrombolysis may improve outcomes, but these are generally reserved for higher-risk patients. Imaging may help guide the use of the newer therapies, but current guidelines focus more on clinical factors. Our goal was to create a risk model that incorporated quantitative echocardiographic and computed tomography (CT) measures of right ventricular (RV) size and function, thrombus burden, and serum biomarkers of cardiac overload or injury. METHODS This was a retrospective study of 150 patients evaluated by a PE response team. Echocardiography was performed within 48 hours of diagnosis. Computed tomography measures included RV/left ventricular (LV) ratio and thrombus load (Qanadli score). Echocardiography was used to obtain various quantitative measures of RV function. We compared characteristics of those who met the primary endpoint (7-day mortality and clinical deterioration) to those who did not. Receiver operating curve analysis was used to assess the performance of different combinations of clinically relevant features and the association with adverse outcomes. RESULTS Fifty-two percent of patients were female, with age 62 ± 17 years, systolic blood pressure 123 ± 25 mm Hg, heart rate 98 ± 19, troponin 3.2 ± 35 ng/dL, and b-type natriuretic peptide (BNP) 467 ± 653. Fourteen (9.3%) were treated with systemic thrombolytics, 27 (18%) underwent catheter-directed thrombolytics, 23 (15%) were intubated or required vasopressors, and 14 (9.3%) died. Patients who met the primary endpoint (44%) versus those who did not (56%) had lower RV S' (6.6 vs 11.9 cm/sec; P < .001) and RV free wall strain (-10.9% vs -13.6%; P = .005), higher RV/LV ratio on CT, and higher serum BNP and troponin levels. Receiver operating curve analysis demonstrated an area under the curve of 0.89 for a model that included RV S', RV free wall strain and tricuspid annular plane systolic excursion/RV systolic pressure ratio from echo, thrombus load and RV/LV ratio from CT, and troponin and BNP levels. CONCLUSION A combination of clinical, echo, and CT findings that reflect the hemodynamic effects of the embolism identified patients with adverse events related to acute PE. Optimized scoring systems that focus on reversible abnormalities attributable to PE may allow more appropriate triaging of intermediate- to high-risk patients with PE for early interventional strategy.
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Affiliation(s)
- Shailee Shah
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Alexis Violette Ogbonna
- Department of Family Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jay Nance
- Houston Methodist Academic Institute, Houston, Texas
| | - Mathew J Gregoski
- Department of Public Health Services, Medical University of South Carolina, Charleston, South Carolina
| | - Ryan Tedford
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Bhavadharini Ramu
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Thomas M Todoran
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Department of Medicine, Division of Cardiology, Ralph H. Johnson Veterans Affairs Health Network, Charleston, South Carolina
| | - Sheldon E Litwin
- Department of Medicine, Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina; Department of Medicine, Division of Cardiology, Ralph H. Johnson Veterans Affairs Health Network, Charleston, South Carolina.
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Bradley CA, Ma C, Hollon MM. Perioperative Point of Care Ultrasound for Hemodynamic Assessment: A Narrative Review. Semin Cardiothorac Vasc Anesth 2023; 27:208-223. [PMID: 36943777 DOI: 10.1177/10892532231165088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
While transesophageal echocardiography (TEE) has traditionally been used in perioperative care, there is growing evidence supporting point of care ultrasound (POCUS) for the anesthesiologist in guiding patient care. It is a quick way to non-invasively evaluate hemodynamically unstable patients and ascertain their state of shock, determine volume status, and guide resuscitation in cardiac arrest. In addition, through use of POCUS, the anesthesiologist is able to identify signs of chronic heart disease to provide a more tailored and safer approach to perioperative care.
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Affiliation(s)
- Caitlin A Bradley
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Chris Ma
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
| | - McKenzie M Hollon
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA, USA
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Wang G, Xu J, Lin X, Lai W, Lv L, Peng S, Li K, Luo M, Chen J, Zhu D, Chen X, Yao C, Wu S, Huang K. Machine learning-based models for predicting mortality and acute kidney injury in critical pulmonary embolism. BMC Cardiovasc Disord 2023; 23:385. [PMID: 37533004 PMCID: PMC10399014 DOI: 10.1186/s12872-023-03363-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/22/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES We aimed to use machine learning (ML) algorithms to risk stratify the prognosis of critical pulmonary embolism (PE). MATERIAL AND METHODS In total, 1229 patients were obtained from MIMIC-IV database. Main outcomes were set as all-cause mortality within 30 days. Logistic regression (LR) and simplified eXtreme gradient boosting (XGBoost) were applied for model constructions. We chose the final models based on their matching degree with data. To simplify the model and increase its usefulness, finally simplified models were built based on the most important 8 variables. Discrimination and calibration were exploited to evaluate the prediction ability. We stratified the risk groups based on risk estimate deciles. RESULTS The simplified XGB model performed better in model discrimination, which AUC were 0.82 (95% CI: 0.78-0.87) in the validation cohort, compared with the AUC of simplified LR model (0.75 [95% CI: 0.69-0.80]). And XGB performed better than sPESI in the validation cohort. A new risk-classification based on XGB could accurately predict low-risk of mortality, and had high consistency with acknowledged risk scores. CONCLUSIONS ML models can accurately predict the 30-day mortality of critical PE patients, which could further be used to reduce the burden of ICU stay, decrease the mortality and improve the quality of life for critical PE patients.
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Affiliation(s)
- Geng Wang
- Department of Vascular Interventional Radiology, Zhongshan Hospital of Traditional Chinese Medicine, Zhongshan, China
| | - Jiatang Xu
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.33, Yingfeng Road, Haizhu District, Guangdong Province, 510000, Guangzhou, China
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Xixia Lin
- Department of Medicine, Sun Yat-Sen Memorial Hospital South Campus Clinic, Guangzhou, China
| | - Weijie Lai
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Lin Lv
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Senyi Peng
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Kechen Li
- Hospital of Stomatology, Guanghua School of Stomatology, Sun Yat-Sen University, Guangzhou, China
| | - Mingli Luo
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China
| | - Jiale Chen
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Dongxi Zhu
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Xiong Chen
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China
| | - Chen Yao
- Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Shaoxu Wu
- Department of Urology, SunYat-Sen Memorial Hospital, SunYat-Sen University, Guangzhou, China.
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Guangzhou, China.
| | - Kai Huang
- Department of Cardiovascular Surgery, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, No.33, Yingfeng Road, Haizhu District, Guangdong Province, 510000, Guangzhou, China.
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Hsu SH, Ko CH, Chou EH, Herrala J, Lu TC, Wang CH, Chang WT, Huang CH, Tsai CL. Pulmonary embolism in United States emergency departments, 2010-2018. Sci Rep 2023; 13:9070. [PMID: 37277498 DOI: 10.1038/s41598-023-36123-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 05/30/2023] [Indexed: 06/07/2023] Open
Abstract
Little is known about pulmonary embolism (PE) in the United States emergency department (ED). This study aimed to describe the disease burden (visit rate and hospitalization) of PE in the ED and to investigate factors associated with its burden. Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2010 to 2018. Adult ED visits with PE were identified using the International Classification of Diseases codes. Analyses used descriptive statistics and multivariable logistic regression accounting for the NHAMCS's complex survey design. Over the 9-year study period, there were an estimated 1,500,000 ED visits for PE, and the proportion of PE visits in the entire ED population increased from 0.1% in 2010-2012 to 0.2% in 2017-2018 (P for trend = 0.002). The mean age was 57 years, and 40% were men. Older age, obesity, history of cancer, and history of venous thromboembolism were independently associated with a higher proportion of PE, whereas the Midwest region was associated with a lower proportion of PE. The utilization of chest computed tomography (CT) scan appeared stable, which was performed in approximately 43% of the visits. About 66% of PE visits were hospitalized, and the trend remained stable. Male sex, arrival during the morning shift, and higher triage levels were independently associated with a higher hospitalization rate, whereas the fall and winter months were independently associated with a lower hospitalization rate. Approximately 8.8% of PE patients were discharged with direct-acting oral anticoagulants. The ED visits for PE continued to increase despite the stable trend in CT use, suggesting a combination of prevalent and incident PE cases in the ED. Hospitalization for PE remains common practice. Some patients are disproportionately affected by PE, and certain patient and hospital factors are associated with hospitalization decisions.
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Affiliation(s)
- Shu-Hsien Hsu
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
| | - Chia-Hsin Ko
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
| | - Eric H Chou
- Department of Emergency Medicine, Baylor Scott and White All Saints Medical Center, Fort Worth, TX, USA
| | - Jeffrey Herrala
- Department of Emergency Medicine, Highland Hospital-Alameda Health System, Oakland, CA, USA
| | - Tsung-Chien Lu
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chih-Hung Wang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Wei-Tien Chang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chien-Hua Huang
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chu-Lin Tsai
- Department of Emergency Medicine, National Taiwan University Hospital, 7 Zhongshan S. Rd, Taipei, 100, Taiwan.
- Department of Emergency Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
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Calé R, Pereira H, Ferreira F, Loureiro MJ. Blueprint for developing an effective pulmonary embolism response network. Rev Port Cardiol 2023:S0870-2551(23)00123-3. [PMID: 36893841 DOI: 10.1016/j.repc.2022.06.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 07/24/2021] [Accepted: 06/17/2022] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Acute pulmonary embolism (PE) is a major cause of morbidity and mortality in Portugal. It is the third most common cause of cardiovascular death after stroke and myocardial infarction. However, the management of acute PE remains poorly standardized, and there is a lack of access to mechanical reperfusion when indicated. METHODS AND RESULTS This working group analyzed the current clinical guidelines for the use of percutaneous catheter-directed treatment in this setting and proposed a standardized approach for severe forms of acute PE. This document also proposes a methodology for the coordination of regional resources in order to create an effective PE response network, based on the hub-and-spoke organization design. CONCLUSION This model can be applied at the regional level, but it is desirable to extend it to the national level.
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Affiliation(s)
- Rita Calé
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal.
| | - Hélder Pereira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal; CCUL, CAML, University of Lisbon, Lisbon, Portugal
| | - Filipa Ferreira
- Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
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Cires-Drouet R, LaRocco A, Soldin D, John T, Toursavadkohi S, Nagarsheth K, Dahi S, Marsella J, Mayorga-Carlin M, Sorkin JD, Jones K, Haase D, Hong SN, Lal BK, Griffith B, Ramani G, Taylor B. Left ventricular systolic dysfunction during acute pulmonary embolism. Thromb Res 2023; 223:1-6. [PMID: 36689804 PMCID: PMC10989403 DOI: 10.1016/j.thromres.2023.01.011] [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: 10/13/2022] [Revised: 01/05/2023] [Accepted: 01/11/2023] [Indexed: 01/22/2023]
Abstract
BACKGROUND Heart failure increases the risk of death in acute pulmonary embolism (PE). The role of the left ventricle (LV) in acute PE is not well defined. OBJECTIVE To identify the prevalence of LV systolic dysfunction, morphology, and prognosis of the LV during an acute PE. METHODS Retrospective study (26-months) of patients diagnosed with an acute PE presenting with LV systolic dysfunction at the University of Maryland. RESULTS Among 769 acute PE patients, 78 (10.5 %) had LV systolic dysfunction and 42 (53.8 %) had history of cardiac disease. Patients without history of cardiac disease were younger (mean age [SD] 54.9 [16.8] vs. 62.6 [16.6]; p = 0.04), had a higher BMI (31.2 [12.2] vs. 29.2 [7.7]; p = 0.005), and less hypertension (20 [34.5 %] vs. 38 [65.5 %]; p = 0.0005). A massive PE was most common in patients without history of cardiac disease (8[22.2 %] vs. 2[4.7 %], p = 0.02). There was no difference in clot burden, but right ventricular strain was more frequently seen in patients without history cardiac disease in the initial CT (p = 0.001). The median troponin and lactate were similar in both groups. In 41 patients with follow-up echocardiograms, improvement in LVEF% was observed in patients without cardiac history (median Δ LVEF% [IQR]; 20 [6.2-25.0]). While patients with cardiac disease did not demonstrate similar changes (median Δ LVEF% [IQR]; 0 [-5-17.5]; p = 0.01). In hospital mortality was 12.8 % with no difference between both groups (p = 0.17). CONCLUSION Pulmonary embolism can be associated with LV systolic dysfunction, even in patients without history of cardiac disease.
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Affiliation(s)
| | - Allison LaRocco
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Danielle Soldin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas John
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | | | - Siamak Dahi
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Justin Marsella
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | | | - John D Sorkin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; Baltimore VA Geriatrics Research, Education, and Clinical Center, Baltimore Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Kevin Jones
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Daniel Haase
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA; The R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Susie N Hong
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, MD, USA; Vascular Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Bartley Griffith
- Department of Surgery, University of Maryland, Baltimore, MD, USA
| | - Gautam Ramani
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley Taylor
- Department of Surgery, University of Maryland, Baltimore, MD, USA
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George TJ, Sheasby J, Sawhney R, DiMaio JM, Afzal A, Gable D, Sayfo S. Extracorporeal membrane oxygenation for large pulmonary emboli. Proc AMIA Symp 2023; 36:314-317. [PMID: 37091759 PMCID: PMC10120470 DOI: 10.1080/08998280.2023.2171699] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
Massive and submassive pulmonary emboli (PE) are increasingly being treated with percutaneous lytic and embolectomy procedures. While these procedures are overwhelmingly safe, patients with significant right ventricular strain are at risk for hemodynamic compromise requiring extracorporeal membrane oxygenation (ECMO). We conducted a retrospective study of all patients requiring ECMO support for PE from 2014 through 2022. The primary outcome was survival. Secondary outcomes included commonly encountered ECMO complications. From 2014 to 2022, 10 patients with submassive or massive PE required ECMO support. All 10 patients (100%) had right ventricular strain on echocardiography, 7 (70%) had a saddle PE, and 3 (30%) had extensive bilateral PE. Six (60%) patients required cardiopulmonary resuscitation prior to ECMO cannulation, and 4 (40%) were undergoing cardiopulmonary resuscitation while being cannulated. Nine (90%) patients were placed on venoarterial ECMO through the femoral vessels, while 1 (10%) was cannulated with right atrial to pulmonary artery ECMO. The median duration of support was 4 [3-8] days. During their course, 5 patients underwent percutaneous embolectomy, 1 underwent surgical embolectomy, and 4 underwent percutaneous lytic therapy. All patients (100%) survived to ECMO decannulation, and 6 (60%) survived to discharge. With a mean follow-up of 496 days, there were no postdischarge mortalities. In conclusion, although therapy for large PE is well tolerated, a small number of patients will experience periprocedural hemodynamic collapse requiring ECMO support. ECMO for PE patients is associated with acceptable morbidity and mortality. Further investigation is warranted to better characterize which patients are likely to require ECMO support.
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Affiliation(s)
- Timothy J. George
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Jenelle Sheasby
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Rahul Sawhney
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - J. Michael DiMaio
- Cardiac Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Aasim Afzal
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Dennis Gable
- Vascular Surgery, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
| | - Sameh Sayfo
- Cardiology, Baylor Scott and White The Heart Hospital – Plano, Plano, Texas
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Chandra VM, Khaja MS, Kryger MC, Sista AK, Wilkins LR, Angle JF, Sharma AM. Mechanical aspiration thrombectomy for the treatment of pulmonary embolism: A systematic review and meta-analysis. Vasc Med 2022; 27:574-584. [PMID: 36373768 DOI: 10.1177/1358863x221124681] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There are no randomized trials studying the outcomes of mechanical aspiration thrombectomy (MAT) for management of pulmonary embolism (PE). METHODS We performed a systematic review and meta-analysis of existing literature to evaluate the safety and efficacy of MAT in the setting of PE. Inclusion criteria were as follows: studies reporting more than five patients, study involved MAT, and reported clinical outcomes and pulmonary artery pressures. Studies were excluded if they failed to separate thrombectomy data from catheter-directed thrombolysis data. Databases searched include PubMed, EMBASE, Web of Science until April, 2021. RESULTS Fourteen case series were identified, consisting of 516 total patients (mean age 58.4 ± 13.6 years). Three studies had only high-risk PE, two studies had only intermediate-risk PE, and the remaining nine studies had a combination of both high-risk and intermediate-risk PE. Six studies used the Inari FlowTriever device, five studies used the Indigo Aspiration system, and the remaining three studies used the Rotarex or Aspirex suction thrombectomy system. Four total studies employed thrombolytics in a patient-specific manner, with seven receiving local lysis and 17 receiving systemic lysis, and 40 receiving both. A random-effects meta-analyses of proportions of in-hospital mortality, major bleeding, technical success, and clinical success were calculated, which yielded estimate pooled percentages [95% CI] of 3.6% [0.7%, 7.9%], 0.5% [0.0%, 1.8%], 97.1% [94.8%, 98.4%], and 90.7% [85.5%, 94.3%]. CONCLUSION There is significant heterogeneity in clinical, physiologic, and angiographic data in the currently available data on MAT. RCTs with consistent parameters and outcomes measures are still needed.
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Affiliation(s)
- Vishnu M Chandra
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Minhaj S Khaja
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Marc C Kryger
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Akhilesh K Sista
- Department of Radiology, Division of Vascular & Interventional Radiology, NYU Langone Health, New York, NY, USA
| | - Luke R Wilkins
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - John F Angle
- Department of Radiology & Medical Imaging, Division of Vascular & Interventional Radiology, University of Virginia Health, Charlottesville, VA, USA
| | - Aditya M Sharma
- Department of Medicine, Division of Cardiovascular Medicine, University of Virginia Health, Charlottesville, VA, USA
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Gheith Z, Alqam B, Jagana R. A Rare Case of Pulmonary Emboli Presenting With ST Elevation on ECG. Cureus 2022; 14:e29249. [PMID: 36262957 PMCID: PMC9574350 DOI: 10.7759/cureus.29249] [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] [Accepted: 09/16/2022] [Indexed: 11/17/2022] Open
Abstract
Pulmonary embolism is a common medical emergency and often life threatening but can be misdiagnosed frequently leading to fatal outcomes. Changes in electrocardiogram (ECG) are common in pulmonary embolism and rarely they can present with ST elevation. We here describe a 79-year-old woman who presented after a cardiac arrest and was found have ST-segment elevation on ECG with normal coronary angiogram while CT scan revealing pulmonary embolism.
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35
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Obstetric Disorders and Critical Illness. Clin Chest Med 2022; 43:471-488. [PMID: 36116815 DOI: 10.1016/j.ccm.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this article, we discuss some of the more common obstetric-related conditions that can lead to critical illness and require management in an ICU. These include the hypertensive disorders of pregnancy, postpartum hemorrhage, hemolysis, elevated liver enzymes, and low platelet syndrome, acute fatty liver of pregnancy, amniotic fluid embolism, and peripartum cardiomyopathy. We also discuss pulmonary embolism and Covid-19. Despite not being specific to obstetric patients, pulmonary embolism is a common, life-threatening diagnosis in pregnancy with particular risks and management aspects. Covid-19 does not seem to occur with higher frequency in pregnant women, but it leads to higher rates of ICU admissions and mechanical ventilation in pregnant women than in their nonpregnant peers. Its prevalence during our current global pandemic makes it important to discuss in this article. We provide a basis for critical care physicians to be engaged in informed conversations and management in a multidisciplinary manner with other relevant providers in the care of critically ill pregnant and postpartum women.
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Angiojet System Used in the Treatment of Submassive Pulmonary Embolism: A Case Report of Two Patients. Case Rep Vasc Med 2022; 2022:6867338. [PMID: 36051456 PMCID: PMC9427312 DOI: 10.1155/2022/6867338] [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: 04/29/2022] [Accepted: 08/01/2022] [Indexed: 11/17/2022] Open
Abstract
Background Massive or submassive pulmonary embolism (PE) carries a high mortality. Percutaneous mechanical thrombectomy using the Angiojet system is accepted for the treatment of PE. Here, we reported two submassive PE cases who were treated with the Angiojet system successfully, to provide some advice for the therapy of submassive PE. Method Two patients with suffocation were admitted to our hospital. One patient was accompanied by lower blood pressure (20% lower than basal blood pressure) and higher pulmonary artery pressure (89 mmHg); the other patient had larger right ventricular transverse diameter (46 mm), decreased left ventricular end diastolic anteroposterior diameter (34 mm), and higher heartbeats (107 heartbeats per minute). Pulmonary artery computed tomography angiography showed bilateral pulmonary embolism. Result The Angiojet system with a high-pressure jet spray pattern (urokinase 25 wiu + sodium chloride injection 50 ml) was used. Intravascular thrombolysis by urokinase (100 wiu/day for 1 day) was done after being back in the ward. And low molecular weight heparin was used in hospitalization, and rivaroxaban was used after discharge. Both patients were treated successfully. However, the level of platelet was significantly lower in one patient after Angiojet system usage and recovered to the preoperative level the next day. Another patient suffered from bradyarrhythmias during the usage of Angiojet, and bradyarrhythmias disappeared when the Angiojet system stopped. Pulmonary embolism was cured after 3 months in both patients. Conclusion Angiojet could be a simple, safe, and well-tolerated treatment for massive or submassive PE. And hematocrit, platelet, kidney function, and heart rhythm should be monitored during perioperation.
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Chopard R, Behr J, Vidoni C, Ecarnot F, Meneveau N. An Update on the Management of Acute High-Risk Pulmonary Embolism. J Clin Med 2022; 11:jcm11164807. [PMID: 36013046 PMCID: PMC9409943 DOI: 10.3390/jcm11164807] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022] Open
Abstract
Hemodynamic instability and right ventricular (RV) dysfunction are the key determinants of short-term prognosis in patients with acute pulmonary embolism (PE). High-risk PE encompasses a wide spectrum of clinical situations from sustained hypotension to cardiac arrest. Early recognition and treatment tailored to each individual are crucial. Systemic fibrinolysis is the first-line pulmonary reperfusion therapy to rapidly reverse RV overload and hemodynamic collapse, at the cost of a significant rate of bleeding. Catheter-directed pharmacological and mechanical techniques ensure swift recovery of echocardiographic parameters and may possess a better safety profile than systemic thrombolysis. Further clinical studies are mandatory to clarify which pulmonary reperfusion strategy may improve early clinical outcomes and fill existing gaps in the evidence.
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Affiliation(s)
- Romain Chopard
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
- Correspondence:
| | - Julien Behr
- Department of Radiology, University Hospital Besançon, 25000 Besancon, France
| | - Charles Vidoni
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
| | - Nicolas Meneveau
- Department of Cardiology, University Hospital Besançon, 25000 Besancon, France
- EA3920, University of Burgundy Franche-Comté, 25000 Besancon, France
- F-CRIN, INNOVTE Network, 42055 Saint-Etienne, France
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Voci D, Zbinden S, Micieli E, Kucher N, Barco S. Fixed-Dose Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Pulmonary Embolism Associated with COVID-19. Viruses 2022; 14:1606. [PMID: 35893672 PMCID: PMC9394471 DOI: 10.3390/v14081606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 11/30/2022] [Accepted: 07/20/2022] [Indexed: 12/07/2022] Open
Abstract
Background. Fixed-dose ultrasound-assisted catheter-directed thrombolysis (USAT) rapidly improves hemodynamic parameters and reverses right ventricular dysfunction caused by acute pulmonary embolism (PE). The effectiveness of USAT for acute PE associated with coronavirus disease 2019 (COVID-19) is unknown. Methods and results. The study population of this cohort study consisted of 36 patients with an intermediate-high- or high-risk acute PE treated with a fixed low-dose USAT protocol (r-tPA 10-20 mg/15 h). Of these, 9 patients tested positive for COVID-19 and were age-sex-matched to 27 patients without COVID-19. The USAT protocol included, beyond the infusion of recombinant tissue plasminogen activator, anti-Xa-activity-adjusted unfractionated heparin therapy (target 0.3-0.7 U/mL). The study outcomes were the invasively measured mean pulmonary arterial pressure (mPAP) before and at completion of USAT, and the National Early Warning Score (NEWS), according to which more points indicate more severe hemodynamic impairment. Twenty-four (66.7%) patients were men; the mean age was 67 ± 14 years. Mean ± standard deviation mPAP decreased from 32.3 ± 8.3 to 22.4 ± 7.0 mmHg among COVID-19 patients and from 35.4 ± 9.7 to 24.6 ± 7.0 mmHg among unexposed, with no difference in the relative improvement between groups (p = 0.84). Within 12 h of USAT start, the median NEWS decreased from six (Q1-Q3: 4-8) to three (Q1-Q3: 2-4) points among COVID-19 patients and from four (Q1-Q3: 2-6) to two (Q1-Q3: 2-3) points among unexposed (p = 0.29). One COVID-19 patient died due to COVID-19-related complications 14 days after acute PE. No major bleeding events occurred. Conclusions. Among patients with COVID-19-associated acute PE, mPAP rapidly decreased during USAT with a concomitant progressive improvement of the NEWS. The magnitude of mPAP reduction was similar in patients with and without COVID-19.
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Affiliation(s)
- Davide Voci
- Department of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.V.); (S.Z.); (E.M.); (N.K.)
| | - Stéphanie Zbinden
- Department of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.V.); (S.Z.); (E.M.); (N.K.)
| | - Evy Micieli
- Department of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.V.); (S.Z.); (E.M.); (N.K.)
| | - Nils Kucher
- Department of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.V.); (S.Z.); (E.M.); (N.K.)
| | - Stefano Barco
- Department of Angiology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.V.); (S.Z.); (E.M.); (N.K.)
- Center for Thrombosis and Hemostasis, Johannes Gutenberg University Mainz, 55131 Mainz, Germany
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Ismail M, Bsooki M, Allehyani B, Alessa A. Inhaled Nitric Oxide (iNO) With a Massive Pulmonary Embolism: A Case Report. Cureus 2022; 14:e27122. [PMID: 36004010 PMCID: PMC9392848 DOI: 10.7759/cureus.27122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2022] [Indexed: 11/17/2022] Open
Abstract
Massive pulmonary embolism (PE) is a type of complication related to the migration of deep venous thrombi clot to the lungs. Massive PE is associated with a high level of morbidity and mortality due to elevated pulmonary vascular resistance that can cause right ventricular failure, cardiogenic shock, and hypoxemia. This report aims to explain to the readers the efficacy of applying inhaled nitric oxide (iNO) to patients with a massive PE. It also aims to evaluate iNO’s pulmonary vasodilator efficacy for acute PE.
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40
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Pagkratis N, Matsagas M, Malli F, Gourgoulianis KI, Kotsiou OS. Prevalence of Hemorrhagic Complications in Hospitalized Patients with Pulmonary Embolism. J Pers Med 2022; 12:jpm12071133. [PMID: 35887630 PMCID: PMC9320949 DOI: 10.3390/jpm12071133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 06/25/2022] [Accepted: 07/12/2022] [Indexed: 12/02/2022] Open
Abstract
Background: The prevalence of anticoagulant therapy-associated hemorrhagic complications in hospitalized patients with pulmonary embolism (PE) has been scarcely investigated. Aim: To evaluate the prevalence of hemorrhages in hospitalized PE patients. Methods: The Information System “ASKLIPIOS™ HOSPITAL” implemented in the Respiratory Medicine Department, University of Thessaly, was used to collect demographic, clinical and outcome data from January 2013 to April 2021. Results: 326 patients were included. Males outnumbered females. The population’s mean age was 68.7 ± 17.0 years. The majority received low molecular weight heparin (LMWH). Only 5% received direct oral anticoagulants. 15% of the population were complicated with hemorrhage, of whom 18.4% experienced a major event. Major hemorrhages were fewer than minor (29.8% vs. 70.2%, p = 0.001). Nadroparin related to 83.3% of the major events. Hematuria was the most common hemorrhagic event. 22% of patients with major events received a transfusion, and 11% were admitted to intensive care unit (ICU). The events lasted for 3 ± 2 days. No death was recorded. Conclusions: 1/5 of the patients hospitalized for PE complicated with hemorrhage without a fatal outcome. The hemorrhages were mainly minor and lasted for 3 ± 2 days. Among LMWHs, nadroparin was related to a higher percentage of hemorrhages.
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Affiliation(s)
| | - Miltiadis Matsagas
- Department of Respiratory Medicine, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | - Foteini Malli
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
| | | | - Ourania S. Kotsiou
- Vascular Surgery Department, Faculty of Medicine, University of Thessaly, 41110 Larissa, Greece;
- Correspondence:
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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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42
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Kim TS. Surgical Embolectomy of Acute Pulmonary Embolism. Phlebology 2022. [DOI: 10.37923/phle.2022.20.1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tae Sik Kim
- Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Seoul, Korea
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43
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Cueto-Robledo G, Rivera-Sotelo N, Roldan-Valadez E, Narvaez-Oriani CA, Cueto-Romero HD, Gonzalez-Hermosillo LM, Hidalgo-Alvarez M, Barrera-Jimenez B. A brief review on failed hybrid treatment for massive pulmonary embolism: catheter-directed thrombolysis (CDT) and pharmaco-mechanical thrombolysis (PMT). Curr Probl Cardiol 2022; 47:101294. [PMID: 35753399 PMCID: PMC9225962 DOI: 10.1016/j.cpcardiol.2022.101294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
Acute massive or high-risk pulmonary embolism (PE), described as a lung arteries occlusion by an embolus, causes a significant compromise of hemodynamic stability and could lead to a lethal event. Systemic fibrinolytic therapy has been accepted as the standard reperfusion therapy in massive PE, except when there is an increased risk of bleeding. Catheter-based mechanical strategies (thrombofragmentation, thromboaspiration with catheter-guided thrombolysis) are described as options when there are absolute contraindications to systemic thrombolysis. We briefly reviewed clinical situations when patients with severe pneumonia due to COVID-19 are complicated by a high-risk saddle pulmonary embolism and underwent repeated pharmacomechanical thrombolysis and high-flow oxygen therapy. There are scarce reports of failed catheter-guided pharmacomechanical thrombolysis in patients with PE secondary to COVID-19. Re-administration of systemic thrombolysis and alteplase (15 mg dose) can show favorable results.
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Affiliation(s)
- Guillermo Cueto-Robledo
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico.
| | - Nathaly Rivera-Sotelo
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Ernesto Roldan-Valadez
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", Mexico City, Mexico; I.M. Sechenov First Moscow State Medical Universit (Sechenov University), Department of Radiology, Moscow, Russia.
| | | | | | - Leslie-Marisol Gonzalez-Hermosillo
- Directorate of Research, Hospital General de Mexico "Dr Eduardo Liceaga", Mexico City, Mexico; I.M. Sechenov First Moscow State Medical Universit (Sechenov University), Department of Radiology, Moscow, Russia
| | - Martin Hidalgo-Alvarez
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
| | - Beatriz Barrera-Jimenez
- Cardiorespiratory emergencies, Hospital General de México "Dr Eduardo Liceaga", Mexico City, Mexico
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44
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Mously H, Hajjari J, Chami T, Hammad T, Schilz R, Carman T, Elgudin Y, Abu-Omar Y, Pelletier MP, Shishehbor MH, Li J. Percutaneous mechanical thrombectomy and extracorporeal membranous oxygenation: A case series. Catheter Cardiovasc Interv 2022; 100:274-278. [PMID: 35686535 DOI: 10.1002/ccd.30295] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 05/03/2022] [Accepted: 05/14/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Massive or high-risk pulmonary embolism (PE) is a potentially life-threatening diagnosis with significant morbidity and mortality if treatment is delayed. Extracorporeal membrane oxygenation (ECMO) and large bore thrombectomy (LBT) in isolation have been used to stabilize and treat patients with massive PE, however, literature describing the combination of both modalities is lacking. We present a case series involving 9 patients who underwent combined ECMO and LBT and their outcomes. METHODS This was a retrospective chart review of patients with confirmed PE, who underwent LBT and ECMO. We retrospectively captured clinical, therapeutic, and outcome data at the time of pulmonary embolism response team (PERT) activation and during the follow-up period for up to 90 days. RESULTS Nine patients who had PERT activation with confirmed PE diagnosis have undergone combined LBT and ECMO initiation since the advent of our PERT program. The median age was 57 (range 28-68) years. Six patients out of 9 (55%) had cardiac arrest before therapy. All patients exhibited right heart strain on computed tomography and echocardiogram. The median ECMO duration was 5 days (range 2.3-11.6 days), with mean hospitalization of 16.1 days (range 1.5-30.9). Mortality was 22% at 90-day follow-up period. CONCLUSION Patients with massive pulmonary embolism who suffer cardiac arrest have significant morbidity and mortality. ECMO in combination with LBT is a viable treatment option for patients with significant hemodynamic compromise.
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Affiliation(s)
- Haytham Mously
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jamal Hajjari
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Tarek Chami
- Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | - Tarek Hammad
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Robert Schilz
- Department of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Teresa Carman
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Yakov Elgudin
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA.,Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Yasir Abu-Omar
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA.,Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Marc P Pelletier
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA.,Division of Cardiac Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Mehdi H Shishehbor
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jun Li
- Harrington Heart and Vascular Institute, University Hospital Cleveland Medical Center, Cleveland, Ohio, USA
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Hara N, Lee T, Nozato T, Terui Matsuyama M, Okata S, Nagase M, Mitsui K, Nitta G, Watanabe K, Miyazaki R, Nagamine S, Kaneko M, Nakamura T, Nagata Y, Miyamoto T, Obayashi T, Ashikaga T. Effectiveness and Safety of Direct Oral Anticoagulants vs. Warfarin and Recurrence After Discontinuation in Patients With Acute Venous Thromboembolism in the Real World. Circ J 2022; 86:923-933. [PMID: 34645732 DOI: 10.1253/circj.cj-21-0588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The efficacy of direct oral anticoagulants (DOACs) compared with warfarin for the treatment of venous thromboembolism (VTE), and the recurrence of VTE after discontinuation of anticoagulation therapy in research are limited. METHODS AND RESULTS This retrospective study enrolled 893 patients with acute VTE between 2011 and 2019. The cohort was divided into the transient risk, unprovoked, continued cancer treatment, and cancer remission groups. The following were compared between DOACs and warfarin: composite outcome of all-cause death, VTE recurrence, bleeding and composite outcome of VTE-related death, recurrence and bleeding. In the continued cancer treatment group, more bleeding was seen in warfarin-treated patients than in patients treated with DOACs (53.2% vs. 31.2%, [P=0.048]). In addition, composite outcome of VTE-related death and recurrence after discontinuation of anticoagulation therapy (n=369) was evaluated. The continued cancer treatment group (multivariate analysis: HR: 3.62, 95% CI: 1.84-7.12, P<0.005) and bleeding-related discontinuation of therapy (HR: 2.60, 95% CI: 1.32-5.13, P=0.006) were independent predictors of the event after discontinuation of anticoagulation therapy. VTE recurrence after discontinuation of anticoagulation therapy in the cancer remission group was 1.6% and a statistically similar occurrence was found in the transient risk group (12.4%) (P=0.754). CONCLUSIONS DOACs may decrease bleeding incidence in patients continuing to receive cancer treatment. In patients with bleeding-related discontinuation of anticoagulation therapy, VTE recurrence may increase. Discontinuation of anticoagulant therapy might be a treatment option in patients who have completed their cancer treatment.
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Affiliation(s)
- Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Tetsumin Lee
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | | | | | - Masashi Nagase
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Kentaro Mitsui
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Giichi Nitta
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | - Sho Nagamine
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Masakazu Kaneko
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | | | | | - Toru Obayashi
- Department of Cardiology, Japanese Red Cross Musashino Hospital
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Maraziti G, Cimini LA, Becattini C. Risk stratification to optimize the management of acute pulmonary embolism. Expert Rev Cardiovasc Ther 2022; 20:377-387. [PMID: 35544707 DOI: 10.1080/14779072.2022.2077194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a life-threatening disease. Risk stratification in patients with acute PE can guide clinical decisions. Clinical assessment, including hemodynamics, respiratory parameters, patient history, and right ventricle evaluation, has a pivotal role in this scope. AREAS COVERED This review aims to describe: i) the role of individual tools for prognostic stratification, from simple clinical parameters to the models suggested by international guidelines; ii) the implications of risk stratification in terms of patient disposition and treatment. The bleeding risk assessment in acute PE was also reviewed. The literature search was performed in PubMed and Embase to address these issues. EXPERT OPINION Prognostic assessment is essential to proceed with life-saving treatments in hemodynamically unstable patients and consider home treatment or short hospital stay in patients at low risk for death. In hemodynamically stable patients, risk stratification allows the implementation of personalized treatment pathways to reduce the risk of death, early PE recurrence, and bleeding. With the aim of optimizing healthcare resources, risk stratification may suggest appropriate patient disposition.
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Affiliation(s)
- Giorgio Maraziti
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Ludovica Anna Cimini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine - Stroke Unit, Ospedale Santa Maria della Misericordia -University of Perugia, Perugia, Italy
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47
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Continuous Aspiration Mechanical Thrombectomy for the management of intermediate- and high-risk pulmonary embolism: Data from the first cohort in Portugal. Rev Port Cardiol 2022; 41:533-545. [DOI: 10.1016/j.repc.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 03/19/2021] [Accepted: 04/07/2021] [Indexed: 12/17/2022] Open
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48
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Russo F, Cianfanelli L, Chieffo A, Galli M, Chizzola G, Bossi I, Capsoni N, Branca L, de Lorenzo L, Zaccone G, Ancona MB, Guerrieri R, Montorfano M. Ultrasound-assisted thrombolysis in high or intermediate-high risk pulmonary embolism patients with contraindications to systemic thrombolysis: A retrospective multicentre experience. Thromb Res 2022; 214:40-43. [DOI: 10.1016/j.thromres.2022.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 10/18/2022]
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49
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Tsai HY, Wang YT, Lee WC, Yen HT, Lo CM, Wu CC, Huang KR, Chen YC, Sheu JJ, Chen YY. Efficacy and Safety of Veno-Arterial Extracorporeal Membrane Oxygenation in the Treatment of High-Risk Pulmonary Embolism: A Retrospective Cohort Study. Front Cardiovasc Med 2022; 9:799488. [PMID: 35310966 PMCID: PMC8924067 DOI: 10.3389/fcvm.2022.799488] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/25/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used to treat high-risk pulmonary embolism (PE). However, its efficacy and safety remain uncertain. This retrospective cohort study aimed to determine whether ECMO could improve the clinical outcomes of patients with high-risk PE. Methods Forty patients with high-risk PE, who were admitted to Kaohsiung Chang Gung Memorial Hospital between January 2012 and December 2019, were included in this study. Demographic data and clinical outcomes were compared between patients treated without ECMO (non-ECMO group) and those treated with ECMO (ECMO group). Appropriate statistical tools were used to compare variables between groups and the survival was analyzed using the Kaplan-Meier method. Results The overall in-hospital mortality rate was 55%, in which 65% (26/40) of patients presented with cardiac arrest with a mortality rate of 77%, which was higher than that of patients without cardiac arrest (14%). There was no significant difference in major complications and in-hospital mortality between the non-ECMO and ECMO groups. However, in subgroup analysis, compared with patients treated without ECMO, earlier ECMO treatment was associated with a reduced risk of cardiac arrest (P = 0.023) and lower in-hospital mortality (P = 0.036). A log-rank test showed a significantly higher cumulative overall survival in the earlier ECMO treatment group (P = 0.033). Conclusions In this retrospective cohort study, earlier ECMO treatment was associated with lower in-hospital mortality among unstable patients without cardiac arrest. Our findings suggest that ECMO can be considered as an initial treatment option for patients with high-risk PE in higher-volume hospitals.
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Affiliation(s)
- Hao-Yu Tsai
- Kaohsiung Chang Gung Memorial Hospital Education Department, Kaohsiung, Taiwan
| | - Yu-Tang Wang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Wei-Chieh Lee
- Division of Cardiology, Department of Internal Medicine, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Hsu-Ting Yen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chien-Ming Lo
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chia-Chen Wu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kwan-Ru Huang
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yin-Chia Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jiunn-Jye Sheu
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Yen-Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung University College of Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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50
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Zimmermann L, Laufs U, Petros S, Lenk K. Outcome After Thrombolysis in Patients With Intermediate High-Risk Pulmonary Embolism: A Propensity Score Analysis. J Emerg Med 2022; 62:378-389. [PMID: 35042625 DOI: 10.1016/j.jemermed.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 10/13/2021] [Accepted: 10/17/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND The role of thrombolytic treatment in patients with intermediate high-risk pulmonary embolism (IHR-PE) remains controversial. OBJECTIVES In this study, we assessed whether systemic thrombolysis decreases hemodynamic decompensation and mortality in a cohort of unselected patients with IHR compared with patients with conventional anticoagulation. METHODS Between January 2014 and December 2018, 137 patients with IHR-PE were identified among 539 consecutive patients treated for symptomatic PE. In 35 patients (25.5%), systemic thrombolysis was used. Propensity score matching was performed based on 17 pretreatment variables. The primary outcome was hemodynamic decompensation, defined by systolic hypotension, need for catecholamines or signs of end-organ hypoperfusion, and all-cause mortality during hospitalization. Secondary outcomes, such as 1-year survival, and safety outcomes, such as bleeding events, were analyzed. RESULTS The effects of systemic thrombolysis and anticoagulation were compared in 55 matched patients with IHR-PE (systemic thrombolysis n = 21; anticoagulation n = 34). Thrombolysis was associated with a reduction (0% vs. 31%; p = 0.004) of the primary outcome during hospitalization and a 1-year survival benefit (100% vs. 83.2%; p = 0.036). Severe bleeding events occurred in 4.8% vs. 0% (p = 0.382) and moderate bleeding was observed in 14.3% vs. 7.1% (p = 0.359) in patients with thrombolysis compared with anticoagulation, respectively. CONCLUSIONS Thrombolysis was associated with a significant reduction of the combined endpoint of hemodynamic decompensation and death during hospitalization and lower all-cause mortality after 1 year in an unselected group of patients with IHR-PE. Further studies are required to improve the therapy of IHR-PE and to identify the subgroup of patients that might benefit from thrombolytic therapy.
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Affiliation(s)
- Luisa Zimmermann
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Karsten Lenk
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
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