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

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

Ultrasound-Assisted Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

2018 ◽  
Vol 52 (3) ◽  
pp. 195-201 ◽  
Author(s):  
Prasoon P. Mohan ◽  
John J. Manov ◽  
Francisco Contreras ◽  
Michael E. Langston ◽  
Mehul H. Doshi ◽  
...  
Keyword(s):  
Risk Factors ◽  
Pulmonary Embolism ◽  
Bleeding Risk ◽  
Right Heart ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Ultrasound Assisted ◽  
Vascular Obstruction ◽  
The Right ◽  
Pulmonary Vascular Obstruction

Purpose: Catheter-directed thrombolysis (CDT) is a relatively new therapy for pulmonary embolism that achieves the superior clot resolution compared to systemic thrombolysis while avoiding the high bleeding risk intrinsically associated with that therapy. In order to examine the efficacy and safety of CDT, we conducted a retrospective cohort study of patients undergoing ultrasound-assisted CDT at our institution. Methods: The charts of 30 consecutive patients who underwent CDT as a treatment of pulmonary embolism at our institution were reviewed. Risk factors for bleeding during thrombolysis were noted. Indicators of the right heart strain on computed tomography and echocardiogram, as well as the degree of pulmonary vascular obstruction, were recorded before and after CDT. Thirty-day mortality and occurrence of bleeding events were recorded. Results: Nine (30%) patients had 3 or more minor contraindications to thrombolysis and 14 (47%) had major surgery in the month prior to CDT. Right ventricular systolic pressure and vascular obstruction decreased significantly after CDT. There was a significant decrease in the proportion of patients with right ventricular dilation or hypokinesis. Decrease in pulmonary vascular obstruction was associated with nadir of fibrinogen level. No patients experienced major or moderate bleeding attributed to CDT. Conclusion: Catheter-directed thrombolysis is an effective therapy in rapidly alleviating the right heart strain that is associated with increased mortality and long-term morbidity in patients with pulmonary embolism with minimal bleeding risk. Catheter-directed thrombolysis is a safe alternative to systemic thrombolysis in patients with risk factors for bleeding such as prior surgery. Future studies should examine the safety of CDT in patients with contraindications to systemic thrombolysis.

Same-Day ICU Discharge in Selected Patients With Severe Submassive Pulmonary Embolism Treated With Catheter-Directed Thrombolysis

2019 ◽  
Vol 54 (1) ◽  
pp. 58-64 ◽  
Author(s):  
Jaideep Das Gupta ◽  
John Marek ◽  
Muhammad Ali Rana ◽  
Sundeep Guliani
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricle ◽  
Right Heart ◽  
Heart Dysfunction ◽  
Catheter Directed Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Icu Discharge ◽  
Same Day Discharge ◽  
Right Heart Dysfunction

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.

Assessment of Anticoagulation in Patients Receiving Ultrasound-Assisted Catheter-Directed Thrombolysis for Treatment of Pulmonary Embolism

2018 ◽  
Vol 53 (5) ◽  
pp. 453-457
Author(s):  
Bradley P. St. Pierre ◽  
Stephanie B. Edwin
Keyword(s):  
Pulmonary Embolism ◽  
Retrospective Chart Review ◽  
Primary Objective ◽  
Bleeding Complications ◽  
Anticoagulation Management ◽  
Institutional Review ◽  
Catheter Directed Thrombolysis ◽  
Submassive Pulmonary Embolism ◽  
Ultrasound Assisted ◽  
Full Intensity

Background: Ultrasound-assisted, catheter-directed thrombolysis (USAT) has emerged as a popular treatment option for submassive pulmonary embolism (PE). The optimal strategy for transitioning patients from full-intensity to reduced-intensity heparin during the procedure has yet to be established. Objective: The goal of this study was to evaluate the anticoagulation management in patients receiving catheter-directed thrombolysis with USAT. Methods: A retrospective chart review was conducted of patients who received USAT for the treatment of PE. Institutional review board approval was obtained. The primary objective was to determine the proportion of patients with a therapeutic activated partial thromboplastin time (aPTT) prior to and during tissue-plasminogen activator (tPA) infusion. Secondary outcomes included heparin requirements, the rate of bleeding complications, and the appropriateness of long-term venous thromboembolism management. Results: A therapeutic aPTT value was achieved in 32 patients (54.2%) prior to USAT and 35 patients (59.3%) during tPA infusion. Heparin requirements were reduced from 15.1 ± 4.1 to 12.8 ± 4.2 U/kg/h for patients who achieved a therapeutic aPTT both prior to and during tPA infusion. Bleeding occurred in 34.4% of patients and tended to be minimal (20.3%) or minor (10.9%). The majority of patients were discharged on a direct oral anticoagulant (63%), followed by warfarin (32%) and enoxaparin (5%). Conclusion and Relevance: To our knowledge, this is the first study that has assessed heparin management in the setting of USAT. The results of these data may aid in empirically dose adjusting unfractionated heparin to ensure safe and effective anticoagulation for patients receiving USAT.

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

Perfusion ◽  
2020 ◽  
Vol 35 (7) ◽  
pp. 641-648 ◽  
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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