scholarly journals Unloading of Right Ventricle and Clinical Improvement after Ultrasound-Accelerated Thrombolysis in Patients with Submassive Pulmonary Embolism

2014 ◽  
Vol 2014 ◽  
pp. 1-8 ◽  
Author(s):  
Sachin Kumar Amruthlal Jain ◽  
Brijesh Patel ◽  
Wadie David ◽  
Ayad Jazrawi ◽  
Patrick Alexander
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricle ◽  
Right Ventricular ◽  
Case Series ◽  
Hemodynamic Instability ◽  
Acute Setting ◽  
Systemic Thrombolysis ◽  
Increased Risk ◽  
Right Ventricular Strain ◽  
Submassive Pulmonary Embolism

Acute pulmonary embolism (PE) can be devastating. It is classified into three categories based on clinical scenario, elevated biomarkers, radiographic or echocardiographic features of right ventricular strain, and hemodynamic instability. Submassive PE is diagnosed when a patient has elevated biomarkers, CT-scan, or echocardiogram showing right ventricular strain and no signs of hemodynamic compromise. Thromboemboli in the acute setting increase pulmonary vascular resistance by obstruction and vasoconstriction, resulting in pulmonary hypertension. This, further, deteriorates symptoms and hemodynamic status. Studies have shown that elevated biomarkers and right ventricular (RV) dysfunction have been associated with increased risk of mortality. Therefore, aggressive treatment is necessary to “unload” right ventricle. The treatment of submassive PE with thrombolysis is controversial, though recent data have favored thrombolysis over conventional anticoagulants in acute setting. The most feared complication of systemic thrombolysis is intracranial or major bleeding. To circumvent this problem, a newer and safer approach is sought. Ultrasound-accelerated thrombolysis is a relatively newer and safer approach that requires local administration of thrombolytic agents. Herein, we report a case series of five patients who underwent ultrasound-accelerated thrombolysis with notable improvement in symptoms and right ventricular function.

Low-Dose Alteplase for the Treatment of Submassive Pulmonary Embolism: A Case Series

2019 ◽  
Vol 33 (5) ◽  
pp. 708-711 ◽  
Author(s):  
Sara N. Layman ◽  
Tommie J. Guidry ◽  
Amanda R. Gillion
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricle ◽  
Low Dose ◽  
Case Series ◽  
Bleeding Events ◽  
Efficacious Treatment ◽  
Increased Risk ◽  
Submassive Pulmonary Embolism ◽  
Successful Resolution ◽  
Ventricle Size

Purpose: Pulmonary embolism (PE) can lead to significant morbidity and mortality. Thrombolytics are currently approved for the treatment of massive PE; however, the CHEST guidelines recommend against systemic thrombolytic use in acute PE patients without hypotension, unless these patients deteriorate on anticoagulation alone. Several studies have demonstrated the effectiveness of thrombolysis in submassive PE; however, the full thrombolytic dose resulted in significantly increased risk of non-intracranial bleeding and hemorrhagic stroke. The MOPETT trial demonstrated that low-dose tissue plasminogen activator (tPA) significantly reduced the risk of pulmonary hypertension and recurrent PE compared to anticoagulation alone in submassive PE patients without any bleeding events. Summary: This case series highlights 5 patient cases utilizing low-dose tPA for submassive PE. All patients had successful resolution of their symptoms and improvement in vitals and laboratory values. Furthermore, no patient had any bleeding during or after tPA administration. Three patients showed improved right ventricle function and reduced or normal right ventricle size on echocardiogram after tPA administration. Conclusion: The potential for low-dose tPA as a safe and efficacious treatment option for submassive PE is illustrated by this case series. However, larger, randomized controlled trials are needed to establish low-dose tPA as an accepted treatment modality.

scholarly journals Catheter-directed therapy for submassive pulmonary embolism after unsuccessful systemic thrombolysis

2017 ◽  
Vol 8 (1) ◽  
pp. 204589321773626 ◽  
Author(s):  
Chang Dong ◽  
Shufen Jiang ◽  
Donghua Ji ◽  
Yingqun Ji ◽  
Zhonghe Zhang
Keyword(s):  
Pulmonary Embolism ◽  
Respiratory Failure ◽  
Right Ventricular ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Systemic Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Life Threatening

Catheter-directed therapy (CDT) has emerged as an important treatment for pulmonary embolism (PE). We present a patient with life-threatening submassive PE with transient hypotension, progressive right ventricular dysfunction, and respiratory failure who failed anticoagulation and had little improvement with systemic thrombolysis, but responded well to catheter-directed therapy.

scholarly journals Systemic Thrombolytic Therapy for Massive and Submassive Pulmonary Embolism

2018 ◽  
Vol 33 (1) ◽  
pp. 74-89 ◽  
Author(s):  
Lauren A. Igneri ◽  
John M. Hammer
Keyword(s):  
Pulmonary Embolism ◽  
Thrombolytic Therapy ◽  
English Language ◽  
Right Ventricular Dysfunction ◽  
Hemodynamic Instability ◽  
Minor Bleeding ◽  
Increased Risk ◽  
Submassive Pulmonary Embolism ◽  
Systemic Thrombolytic Therapy

Objective: To critically evaluate the published literature assessing the safety and efficacy of thrombolytic therapy for massive and submassive pulmonary embolism (PE). Methods: A search of human trials in the English-language (September 2017) was conducted through the MEDLINE database using the following terms: PE, tissue plasminogen activator, tenecteplase, and alteplase. 67 unique articles were identified, of which 24 clinical trials discussing clinical outcomes related to administration of either intravenous tenecteplase or alteplase were included. Results: Thrombolytic therapy with anticoagulation significantly reduced mortality compared to anticoagulation alone in massive PE. In submassive PE, thrombolytics reduced the rate of right ventricular dysfunction and hemodynamic collapse; however, there is an increased risk of major and minor bleeding with no benefit on long-term functional outcomes. Conclusions: Patients with massive PE should receive thrombolytics when no major contraindications to therapy exist. Patients with submassive PE at highest risk for progression to hemodynamic instability should receive anticoagulation and be monitored for clinical deterioration. If an imminent risk of hemodynamic instability or cardiac arrest occurs, thrombolytics should be administered if no contraindications exist. Net mortality benefit and risk of bleeding must be considered when deciding to administer thrombolytic therapy in massive or submassive PE.

scholarly journals Pseudo-Wellens’ syndrome in pulmonary embolism

2018 ◽  
Vol 11 (1) ◽  
pp. e227464 ◽  
Author(s):  
Yub Raj Sedhai ◽  
Soney Basnyat ◽  
Priyanka T Bhattacharya
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Temporal Association ◽  
Ecg Changes ◽  
T Wave ◽  
Wave Inversion ◽  
Free Interval ◽  
Increased Risk ◽  
Right Ventricular Strain ◽  
The Right

Wellens’ syndrome is described as characteristic biphasic or symmetrical T-wave inversion with normal precordial R-wave progression and the absence of Q waves in the right precordial leads. It is seen during chest pain-free interval in a subset of patients with unstable angina. Wellens’ syndrome is associated with critical stenosis of proximal left anterior descending (LAD) coronary artery. Similar characteristic ECG changes associated with causes other than LAD stenosis have been described as pseudo-Wellens’ syndrome. In this case report, we present a young 22-year-old man who presented with characteristic Wellens’ ECG changes in the setting of pulmonary embolism with right ventricular strain. T-wave inversion in right precordial leads is a well-recognised ECG manifestation of right ventricular strain; however, biphasic T waves in the setting of pulmonary embolism are rare. Pulmonary embolism was seen in our patient a week after starting risperidone. There is a reported association between antipsychotic drugs and increased risk of thromboembolism. Risperidone could have potentially contributed to the pulmonary embolism in our patient given the temporal association and absence of risk factors.

scholarly journals Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 35 (02) ◽  
pp. 122-128 ◽  
Author(s):  
Matthew Chiarello ◽  
Akhilesh Sista
Keyword(s):  
Pulmonary Embolism ◽  
The United States ◽  
Similar Efficacy ◽  
Major Hemorrhage ◽  
Systemic Thrombolysis ◽  
Clinical Endpoints ◽  
Catheter Directed Thrombolysis ◽  
Right Ventricular Strain ◽  
Submassive Pulmonary Embolism

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

Echocardiographic assessment with right ventricular function improvement following ultrasound-accelerated catheter-directed thrombolytic therapy in submassive pulmonary embolism

Vascular ◽  
2017 ◽  
Vol 26 (3) ◽  
pp. 271-277 ◽  
Author(s):  
Charles Doheny ◽  
Lorena Gonzalez ◽  
Stanley M Duchman ◽  
Joseph Varon ◽  
Carlos F Bechara ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Left Ventricle ◽  
Right Ventricle ◽  
Right Ventricular ◽  
Ventricular Function ◽  
Right Ventricular Function ◽  
Right Ventricular Dysfunction ◽  
Submassive Pulmonary Embolism ◽  
Echocardiographic Assessment

Introduction The objective of this study was to evaluate the efficacy of ultrasound-accelerated catheter-directed thrombolytic therapy in patients with submassive pulmonary embolism. Methods Clinical records of 46 patients with submassive pulmonary embolism who underwent ultrasound-accelerated catheter-directed pulmonary thrombolysis using tissue plasminogen activator, from 2007 to 2017, were analyzed. All patients experienced clinical symptoms with computed tomography evidence of pulmonary thrombus burden. Right ventricular dysfunction was present in all patients by echocardiographic finding of right ventricle-to-left ventricle ratio > 0.9. Treatment outcome, procedural complications, right ventricular pressures, and thrombus clearance were evaluated. Follow-up evaluation included echocardiographic assessment of right ventricle-to-left ventricle ratio at one month, six months, and one year. Results Technical success was achieved in all patients ( n = 46, 100%). Our patients received an average of 18.4 ± 4.7 mg of tissue plasminogen activator using ultrasound-accelerated thrombolytic catheter with an average infusion time of 16.5± 5.4 h. Clinical success was achieved in all patients (100%). Significant reduction of mean pulmonary artery pressure occurred following the treatment, which decreased from 36 ± 8 to 21 ± 5 mmHg ( p < 0.001). There were no major bleeding complications. All-cause mortality at 30 days was 0%. No patient developed recurrent pulmonary embolism during follow-up. During the follow-up period, 43 patients (93%) showed improvement of right ventricular dysfunction based on echocardiographic assessment. The right ventricle-to-left ventricle ratio decreased from 1.32 ± 0.18 to 0.91 ± 0.13 at the time of hospital discharge ( p < 0.01). The right ventricular function remained improved at 6 months and 12 months of follow-up, as right ventricle-to-left ventricle ratio were 0.92 ± 0.14 ( p < 0.01) and 0.91 ± 0.15 ( p < 0.01), respectively. Conclusion Ultrasound-accelerated catheter-directed thrombolysis is a safe and efficacious treatment for submassive pulmonary embolism. It reduces pulmonary hypertension and improves right ventricular function in patients with submassive pulmonary embolism.

scholarly journals Acute pulmonary embolism and systemic thrombolysis in the era of COVID-19 global pandemic 2020: a case series of seven patients admitted to a regional hospital in the French epidemic cluster

2021 ◽  
Author(s):  
John Philippe ◽  
Elena-Mihaela Cordeanu ◽  
Marie-Béatrice Leimbach ◽  
Stéphane Greciano ◽  
Wael Younes
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Cardiogenic Shock ◽  
Case Series ◽  
Left Ventricular ◽  
Guideline Recommendation ◽  
Severity Scale ◽  
Systemic Thrombolysis ◽  
Increased Risk ◽  
Venous Thromboembolic Events

Abstract Background The novel Coronavirus [named severe acute respiratory syndrome-related coronavirus 2 (SARS CoV-2)] was associated with the development of acute respiratory distress syndrome (ARDS), which required mechanical ventilation in a high percentage of critically ill patients. Recent studies have highlighted a state of hypercoagulability in patients with SARS-CoV-2, leading to an increased risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). The low proportion of PE-associated to DVT in COVID-19 patients may suggest that they have pulmonary thrombosis rather than embolism. There is no guideline recommendation on the treatment of massive PE in COVID-19 patients suffering from ARDS, without cardiogenic shock. Case summary We described a series of seven SARS-COV-2 patients diagnosed with PE, in our institution, who underwent the use of systemic thrombolysis (recombinant tissue plasminogen activator) according to the standard protocol of 10 mg over 15 min, then 90 mg over 120 min. Discussion According to the European Society of Cardiology (ESC) severity scale, three patients had high-risk PE and four had intermediate high-risk PE. Systemic thrombolysis was found to be associated with a reduction of the Brescia-COVID Respiratory Severity Scale in five patients, recording a reduction from 3 to 1 in 2/5 patients, and from 3 to 2 in 3/5 patients. Furthermore, 3/5 patients had an initial improvement of their alveolar partial pressure of oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio ranging from a 19% (Patient 3) to a 156% improvement (Patient 6). It was also associated with a decrease of the right ventricular (RV) dysfunction and the RV/left ventricular ratio 24 h later. No major bleeding events occurred after the thrombolysis, but the overall mortality after performing systemic thrombolysis was up to 3/7 patients. Conclusion Despite the low level of knowledge about the underlying pathophysiology of the COVID-19 ARDS, venous thromboembolic events, and the microvascular thrombosis, our findings suggest that in the treatment of PE with RV failure in patients with COVID-19 suffering from ARDS, without cardiogenic shock, systemic thrombolysis should be considered.

Advanced Management Options for Massive and Submassive Pulmonary Embolism

2016 ◽  
Vol 10 (1) ◽  
pp. 30 ◽  
Author(s):  
Sonika Malik ◽  
◽  
Anju Bhardwaj ◽  
Matthew Eisen ◽  
Sanjay Gandhi ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Vena Cava ◽  
Right Ventricular Dysfunction ◽  
Hemodynamic Instability ◽  
Adverse Outcomes ◽  
Intermediate Risk ◽  
Management Options ◽  
Vena Cava Filters ◽  
Submassive Pulmonary Embolism ◽  
Risk Patients

Pulmonary embolism (PE) is an important cause of morbidity and mortality and presents with significant diagnostic and therapeutic challenges. Clinical presentation ranges from mild, nonspecific symptoms to syncope, shock, and sudden death. Patients with hemodynamic instability and/ or signs of right ventricular dysfunction are at high risk for adverse outcomes and may benefit from aggressive therapy and support. Therapeutic anticoagulation is indicated in all patients in the absence of contraindications. Thrombolysis should be strongly considered in selected high- and intermediate-risk patients, either by systemic infusion or percutaneous catheter-directed therapy. Other therapeutic modalities, such as vena cava filters and surgical embolectomy, are options for patients who fail or cannot tolerate anticoagulation and/or thrombolysis. This article reviews the assessment and advanced management options for acute PE with focus on high- and intermediate-risk patients.

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