TREATMENT OF ACUTE SUBMASSIVE PULMONARY EMBOLISM COMPLICATED BY A RIGHT HEART THROMBUS IN TRANSIT WITH TISSUE PLASMINOGEN ACTIVATOR

The field of anticoagulation has become a highly relevant and expanding division of medicine. Clinicians must maintain an adequate knowledge of the indications, risks, and benefits of each particular anticoagulant before utilizing them in patient care. Despite great advancements in anticoagulate therapies, areas of uncertainty exist when applying combined use of anticoagulants. This vignette illustrates a unique circumstance of initial therapy combining argatroban with tissue plasminogen activator (tPA) and subsequent transition to warfarin in the management of submassive pulmonary embolism (PE) caused by heparin-induced thrombocytopenia (HIT). There are currently no other published cases or guidelines that have demonstrated this treatment strategy. We present the case of a 56-year-old African American female who was started on argatroban therapy for submassive bilateral PE secondary to HIT. She required tPA after becoming progressively unstable. The argatroban drip was continued without any hemorrhagic complications. This combination of therapy led to her stabilization, and she was ultimately safely transitioned to warfarin therapy for long term maintenance anticoagulation. Argatroban is effective in the prevention and treatment of life-threatening complications of HIT. Very little research has been conducted in patients receiving tPA followed by anticoagulation therapy. This case highlights the successful therapy with combined use of tPA and argatroban followed by warfarin transition in the treatment of submassive PE caused by HIT. We find that tPA was safe and effective when the initial argatroban failed to stabilize our patient. The continued use of argatroban infusion after tPA did not cause any hemorrhagic complications. Furthermore, the overlap use of warfarin with argatroban until an INR greater than 4 was achieved for maintenance therapy did not contribute to any hemorrhagic complications. We conclude that the combination of tPA and argatroban is effective in the acute management of hemodynamically unstable PE caused by HIT without significant hemorrhagic complications.

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Submassive pulmonary embolism with a right heart thrombus

BMJ Case Reports ◽

10.1136/bcr-2021-242092 ◽

2021 ◽

Vol 14 (7) ◽

pp. e242092

Author(s):

Winnie Yan ◽

Ingrid Gunther ◽

Ali Hafiz ◽

Ronald Goldenberg

Keyword(s):

Pulmonary Embolism ◽

Treatment Options ◽

Right Heart ◽

Intravenous Tissue Plasminogen Activator ◽

Submassive Pulmonary Embolism ◽

Tissue Plasminogen ◽

Optimal Approach ◽

The Right ◽

In Transit ◽

Acute Pe

A 49-year-old woman presented to the hospital with shortness of breath 2 weeks after a left total hip replacement. She was found to have a submassive pulmonary embolism (PE), with her case complicated by the detection of a large mobile clot in transit extending through a patent foramen ovale between the right and left atria. The presence of this free-floating right heart thrombus (FFRHT) increases her risks of stroke and mortality, yet the optimal approach to her treatment was unclear. Ultimately, intravenous tissue plasminogen activator was administered with resolution of the clot. Treatment was complicated by haemodynamically insignificant bleeding at the site of recent surgery. Herein, we further discuss the implications and treatment options for patients with an FFRHT in the setting of an acute PE.

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Tissue plasminogen activator as a novel diagnostic aid in acute pulmonary embolism

VASA ◽

10.1024/0301-1526/a000392 ◽

2014 ◽

Vol 43 (6) ◽

pp. 450-458 ◽

Cited By ~ 1

Author(s):

Julio Flores ◽

Ángel García-Avello ◽

Esther Alonso ◽

Antonio Ruíz ◽

Olga Navarrete ◽

...

Keyword(s):

Pulmonary Embolism ◽

Negative Predictive Value ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Predictive Value ◽

Acute Pulmonary Embolism ◽

Enzyme Linked Immunosorbent Assay ◽

Diagnostic Utility ◽

Tissue Plasminogen ◽

D Dimer

Background: We evaluated the diagnostic efficacy of tissue plasminogen activator (tPA), using an enzyme-linked immunosorbent assay (ELISA) and compared it with an ELISA D-dimer (VIDAS D-dimer) in acute pulmonary embolism (PE). Patients and methods: We studied 127 consecutive outpatients with clinically suspected PE. The diagnosis of PE was based on a clinical probability pretest for PE and a strict protocol of imaging studies. A plasma sample to measure the levels of tPA and D-dimer was obtained at enrollment. Diagnostic accuracy for tPA and D-dimer was determined by the area under the receiver operating characteristic (ROC) curve. Sensitivity, specificity, predictive values, and the diagnostic utility of tPA with a cutoff of 8.5 ng/mL and D-dimer with a cutoff of 500 ng/mL, were calculated for PE diagnosis. Results: PE was confirmed in 41 patients (32 %). Areas under ROC curves were 0.86 for D-dimer and 0.71 for tPA. The sensitivity/negative predictive value for D-dimer using a cutoff of 500 ng/mL, and tPA using a cutoff of 8.5 ng/mL, were 95 % (95 % CI, 88–100 %)/95 % (95 % CI, 88–100 %) and 95 % (95 % CI, 88–100 %)/94 %), respectively. The diagnostic utility to exclude PE was 28.3 % (95 % CI, 21–37 %) for D-dimer and 24.4 % (95 % CI, 17–33 %) for tPA. Conclusions: The tPA with a cutoff of 8.5 ng/mL has a high sensitivity and negative predictive value for exclusion of PE, similar to those observed for the VIDAS D-dimer with a cutoff of 500 ng/mL, although the diagnostic utility was slightly higher for the D-dimer.

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