PROTOCOLIZED USE OF CATHETER-DIRECTED THROMBOLYSIS AND ECHOCARDIOGRAPHY IS HIGHLY EFFECTIVE IN REVERSING ACUTE RIGHT HEART DYSFUNCTION IN SEVERE SUBMASSIVE PULMONARY EMBOLISM PATIENTS

A retrospective review from July 2016 to April 2018 was performed of 23 patients with submassive pulmonary embolism (PE) who received catheter-directed thrombolysis (CDT). Five (22%) of the 23 patients were discharged the same day from the intensive care unit (ICU) following thrombolysis completion. Their presentation, hospital courses, complications, and follow-up are reviewed. All 5 patients were diagnosed using chest computed tomography (CT) demonstrating a clot in the pulmonary vasculature and right ventricle dysfunction based on abnormal right ventricle to left ventricle (RV/LV) ratio. Patients with severe right heart dysfunction (RV/LV ratio ≥1.4) were protocolized to receive CDT via EkoSonic catheters (EKOS Corporation). Postoperatively, patients were admitted to the ICU with continuous alteplase at 1 mg/h. Echocardiography was then performed after 24 hours of therapy to assess right ventricle function and removal of EkoSonic catheters. Patients with reversal of right heart dysfunction and symptomatic improvement received bedside removal of catheters. The mean patient age was 50.6 years and body mass index was 33.6. Mean RV/LV ratio on admission via CT imaging was 1.56, with a mean troponin of 0.44. Interval mean RV/LV ratio on echocardiography after thrombolysis therapy was 0.91. There was a 0% incidence of periprocedural complications. One (20%) patient out of 5 had an emergency department visit 10 days postdischarge for acute shortness of breath, with workup revealing no evidence of recurrent PE. No patient required hospital readmission within 30 days. At the 6-week follow-up, all patients had continued normal right ventricular function noted on echocardiography. This case series demonstrates that for a select population of patients with severe submassive PE, the use of CDT and echocardiography monitoring can facilitate same-day discharge from the ICU.

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Protocolized use of catheter-directed thrombolysis and echocardiography is highly effective in reversing acute right heart dysfunction in severe submassive pulmonary embolism patients

Perfusion ◽

10.1177/0267659119896891 ◽

2020 ◽

Vol 35 (7) ◽

pp. 641-648 ◽

Cited By ~ 1

Author(s):

Sundeep Guliani ◽

Jaideep Das Gupta ◽

Robin Osofsky ◽

John Marek ◽

Muhammad Ali Rana ◽

...

Keyword(s):

Pulmonary Embolism ◽

Right Ventricular ◽

Left Ventricular ◽

Right Heart ◽

Heart Dysfunction ◽

Catheter Directed Thrombolysis ◽

Submassive Pulmonary Embolism ◽

Right Heart Dysfunction ◽

Mean Heart Rate

Objective: The objective of this study was to evaluate the efficacy of protocolized use of catheter-directed thrombolysis and echocardiography in submassive pulmonary embolism patients. Methods: A retrospective study at a single institution of 28 patients that presented with submassive pulmonary embolism from July 2016 to September 2019 was performed. All patients were diagnosed using chest computed tomography demonstrating a pulmonary embolism and abnormal right ventricular to left ventricular ratio. Patients with severe right heart dysfunction (right ventricular to left ventricular ratio ⩾1.4) were protocolized to receive catheter-directed thrombolysis via EkoSonic catheters (EKOS Corporation, Bothell, WA, United States). Transthoracic echocardiogram was performed after 24 hours to assess right ventricular function and determine the need to continue thrombolysis. Patients after discharge then received follow-up echocardiograms at 6 weeks to determine new post-treatment baseline. Results: The mean patient age was 54.6 years, mean body mass index was 35.0, and mean right ventricular to left ventricular ratio on admission computed tomography imaging was 1.70. Interval mean right ventricular to left ventricular ratio on echocardiography during thrombolysis therapy was 1.01 (p < 0.00001). Patients were tachycardic on admission (mean heart rate 102.2 beats per minute) with improvement by completion of thrombolysis (mean heart rate 72.9 beats per minute) (p < 0.00001). There was a 0% incidence of periprocedural complications. Overall 30-day complication rate was 7.1% (n = 1 arrhythmia, n = 1 delayed intracranial hemorrhage). At 6-week follow-up, 91% of the patients who received echocardiography had normal right ventricular function. Conclusion: This retrospective study demonstrates the effectiveness of protocolized use of catheter-directed thrombolysis and echocardiography in reversing severe right heart dysfunction in submassive pulmonary embolism patients.

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Abstract No. 677 Reduced right heart dysfunction following pulmonary embolism treated with catheter-directed therapy: a retrospective study

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2019.12.801 ◽

2020 ◽

Vol 31 (3) ◽

pp. S291

Author(s):

R. Chavda ◽

J. Knott ◽

S. Virani ◽

S. Zamin ◽

A. Saenz

Keyword(s):

Pulmonary Embolism ◽

Retrospective Study ◽

Right Heart ◽

Heart Dysfunction ◽

Right Heart Dysfunction

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Short-term Mortality in Acute Pulmonary Embolism: Clot Burden and Signs of Right Heart Dysfunction at CT Pulmonary Angiography

Radiology ◽

10.1148/radiol.12110802 ◽

2012 ◽

Vol 265 (1) ◽

pp. 283-293 ◽

Cited By ~ 87

Author(s):

Alessandro Furlan ◽

Ayaz Aghayev ◽

Chung-Chou H. Chang ◽

Amol Patil ◽

Kyung Nyeo Jeon ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Pulmonary Angiography ◽

Ct Pulmonary Angiography ◽

Short Term ◽

Right Heart ◽

Heart Dysfunction ◽

Short Term Mortality ◽

Clot Burden ◽

Right Heart Dysfunction

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4:03 PM Abstract No. 228 Ultrasound-assisted catheter-directed thrombolysis for submassive pulmonary embolism: efficacy in relief of right heart strain

Journal of Vascular and Interventional Radiology ◽

10.1016/j.jvir.2018.01.255 ◽

2018 ◽

Vol 29 (4) ◽

pp. S99

Author(s):

J. Manov ◽

F. Contreras ◽

M. Langston ◽

M. Doshi ◽

P. Mohan

Keyword(s):

Pulmonary Embolism ◽

Right Heart ◽

Catheter Directed Thrombolysis ◽

Submassive Pulmonary Embolism ◽

Ultrasound Assisted

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Central thromboembolism is a possible predictor of right heart dysfunction in normotensive patients with acute pulmonary embolism

Yearbook of Pulmonary Disease ◽

10.1016/j.ypdi.2011.02.027 ◽

2011 ◽

Vol 2011 ◽

pp. 124-125

Author(s):

M. Ali Raza

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Right Heart ◽

Heart Dysfunction ◽

Right Heart Dysfunction

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Central thromboembolism is a possible predictor of right heart dysfunction in normotensive patients with acute pulmonary embolism

Thrombosis Research ◽

10.1016/j.thromres.2010.06.009 ◽

2010 ◽

Vol 126 (3) ◽

pp. e201-e205 ◽

Cited By ~ 13

Author(s):

T.M. Berghaus ◽

T. Haeckel ◽

W. Behr ◽

M. Wehler ◽

W. von Scheidt ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Right Heart ◽

Heart Dysfunction ◽

Right Heart Dysfunction

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Risk management in acute pulmonary embolism: correlation between right heart dysfunction, pulmonary clots distribution, biomarkers and prognosis

Italian Journal of Medicine ◽

10.4081/itjm.2008.3.23 ◽

2013 ◽

pp. 23-29

Author(s):

Luca Masotti ◽

Fabio Antonelli ◽

Elio Venturini ◽

Giancarlo Landini

Keyword(s):

Pulmonary Embolism ◽

Pulmonary Artery ◽

Acute Pulmonary Embolism ◽

Troponin I ◽

Main Pulmonary Artery ◽

Shock Index ◽

Right Heart ◽

Heart Dysfunction ◽

Right Heart Dysfunction ◽

D Dimer

BACKGROUND Right heart dysfunction (RHD) is related to adverse outcomes in acute pulmonary embolism (PE). AIM OF THE STUDY To evaluate the relation between RHD, pulmonary clots distribution and biomarkers and prognosis of patients with PE. METHODS We analysed echocardiographic data of 70 patients with diagnosis of PE confirmed by pulmonary computer tomography, hCT. We considered the enddiastolic right/left ventricles ratio > 1 as index of RHD; echocardiographic data were compared with clots distribution in pulmonary vascular tree such as hCT findings and biomarkers. For each patient we calculated the shock index (heart rate/systolic blood pressure ratio, shock defined as ratio ≥ 1). RESULTS Hospital mortality was 8.5%. Mean age of dead patients was significantly higher compared to alive (85.67 vs 71.57 years, p < 0.05). 41% of patients revealed unilateral PE, 59% had bilateral. In 10% of patients main pulmonary artery was interested by clot, 48% of patients had involved one of the main branches, 90% had involved at least one of the lobar branches, 59% one of segmental branches of pulmonary arteries. 52% of patients had RHD. Mortality in RHD patients was 14.8% vs 8% in no RHD, p < 0.05. Mean values of troponin I and D-dimer were significantly higher in RHD patients. Shock index was ≥ 1 in 37.5% of RHD and 20% in no RHD. RHD patients showed significantly higher involvement of main pulmonary artery and its branches and higher bilateral involvement. CONCLUSIONS RHD is related to proximal and bilateral pulmonary clots distribution and troponin I and D-dimer values and poorer prognosis.

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