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.

scholarly journals Systemic Thrombolysis for Treatment of Postpartum Saddle Embolism Complicated by Postpartum Hemorrhage: A Case Report and Brief Literature Review

2021 ◽  
Vol 2021 ◽  
pp. 1-6
Author(s):  
Kathy Mostajeran ◽  
Hillary Boswell ◽  
Ziad Haidar
Keyword(s):  
Pulmonary Embolism ◽  
Case Report ◽  
Postpartum Hemorrhage ◽  
Postpartum Period ◽  
Case Series ◽  
Massive Pulmonary Embolism ◽  
Thromboembolic Events ◽  
Systemic Thrombolysis ◽  
Venous Thromboembolic Events ◽  
In Pregnancy

Venous thromboembolic events (VTE), specifically pulmonary embolisms, account for a significant portion of maternal morbidity and mortality. Due to the procoagulant physiological changes that occur, pregnancy and the postpartum period are known risk factors for thromboembolic events. The risk is greatest during the first-week postpartum and remains elevated for up to six weeks as compared to the general population. Treatment guidelines regarding the use of thrombolytics for massive pulmonary embolism occurring in pregnancy and the postpartum are not well established. In nonpregnant populations, thrombolytic agents are well known to decrease the mortality in the setting of a massive pulmonary embolism. However, in the absence of management guidelines, thrombolysis in pregnancy remains guided by case reports and case series. We present a case of a massive pulmonary embolism (PE) causing hemodynamic instability during the postpartum period treated with tissue plasminogen activator (tPA). The case was complicated by delayed postpartum hemorrhage successfully managed with the uterotonic methylergometrine. The patient was started on oral anticoagulation and continued for six months without recurrent VTE. Our case demonstrates a rare occurrence of a saddle embolism after a vaginal delivery within the first postpartum week which was successfully managed with the use of systemic thrombolysis and minimal intervention to manage the iatrogenic delayed postpartum hemorrhage. To the authors’ knowledge, no other similar case report exists. This case highlights the need to develop guidelines for the use of thrombolysis in mothers who present with massive pulmonary embolus and a noninvasive means to manage adverse bleeding events in the puerperium.

scholarly journals Treatment Difficulties in High Risk Pulmonary Embolism. A Case Report

2016 ◽  
Vol 2 (1) ◽  
pp. 37-42
Author(s):  
Balázs Bajka ◽  
Edvin Benedek ◽  
Alexandra Stănescu ◽  
Emese Rapolti ◽  
Monica Chițu ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Thrombolytic Agent ◽  
Bleeding Risk ◽  
Systemic Thrombolysis ◽  
Catheter Directed Thrombolysis ◽  
Increased Risk ◽  
Life Threatening ◽  
Surgical Embolectomy ◽  
High Bleeding Risk

Abstract Pulmonary embolism (PE) remains a common and potentially life-threatening cardiovascular emergency. Systemic thrombolysis with intravenous infusion of a thrombolytic agent is generally recommended for treatment of high risk PE. However, this method has known limitations in the presence of high bleeding risk. Catheter-directed thrombolysis has the potential to achieve the same benefits as systemic thrombolysis, with a lower risk of haemorrhage. The case presented is of a 67-year-old male patient with a high risk of pulmonary embolism and contraindications for systemic thrombolysis, in whom the presence of severe comorbidities presented an increased risk of surgical embolectomy, who was successfully treated by catheter-directed thrombolysis.

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.

Outcome of Impella 2.5 use in patients undergoing Percutaneous Coronary Intervention in Henan, China: a case series

Perfusion ◽  
2021 ◽  
pp. 026765912110490
Author(s):  
Rafiq Ahmed Bhat ◽  
Syed Manzoor Ali ◽  
Akanksha Rathi ◽  
Javaid Akhter Bhat ◽  
Raja Saqib Iqbal ◽  
...  
Keyword(s):  
Heart Failure ◽  
Percutaneous Coronary Intervention ◽  
High Risk ◽  
Cardiogenic Shock ◽  
Case Series ◽  
Coronary Intervention ◽  
Left Ventricular ◽  
Hemodynamic Support ◽  
Percutaneous Coronary ◽  
Case Number

Background: Acute myocardial infarction (AMI) complicated by cardiogenic shock (AMI-CS) or heart failure is associated with an unacceptably high in-hospital mortality of 33%–55% and a lost chance to accept PCI (Percutaneous Coronary Intervention). Aim: The aim of the study was to find out whether percutaneous hemodynamic support device Impella 2.5 improves prognosis of high-risk PCI patients or not. Methods: This study was a case series involving six patients who underwent a Left Ventricular Assist Device (LVAD, Impella 2.5, Abiomed, Danvers, MA) implantation after suffering from AMI with a very low ejection fraction and acute heart failure. The clinical experience and outcomes of the patients are hereby discussed. Results: All PCI procedures were safely completed under LVAD support. The hemodynamic parameters of all patients improved clinically over the next 30 days and following 12 months after Impella insertion except in two patients, of which one patient (Case number 6) died 4 days post-Impella protected PCI procedure due to acute left ventricle heart failure with cardiogenic shock and pulmonary oedema; and another one died at 12 months after Impella protected PCI procedure (Case number 4) due to decompensated heart failure and infected pneumonia. Conclusion: Percutaneous hemodynamic support is favorable and feasible during high risk Percutaneous Coronary Intervention (PCI). A bigger study is needed to substantiate the claims of the current study.

scholarly journals Acute pulmonary embolism in COVID-19 patient: a case report of free-floating right heart thrombus successfully treated with fibrinolysis

2020 ◽  
Author(s):  
Fernando Scudiero ◽  
Antonino Pitì ◽  
Roberto Keim ◽  
Guido Parodi
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Retrospective Studies ◽  
Right Heart ◽  
Clinical Issue ◽  
Systemic Thrombolysis ◽  
Case Summary ◽  
High Prevalence ◽  
Life Threatening ◽  
Complex Scenario

Abstract Background Despite the fast-growing understanding of the coronavirus disease 2019 (COVID-19), patient management remains largely empirical or based on retrospective studies. In this complex scenario, an important clinical issue appears to be represented by the high prevalence of thromboembolic events, but the data regarding high-risk pulmonary embolism (PE) is still not available. Case summary A patient with COVID-19 developed sudden shortness of breath and hypoxia. Early echocardiographic diagnosis of high-risk PE related to right heart thrombus was performed. Systemic thrombolysis was administered with excellent clinical and haemodynamic response. Discussion Pulmonary thromboembolism is a common occurrence in severe COVID-19 infection. In our experience, systemic thrombolysis proved to be effective and for this reason may be considered for life-threatening PE in COVID-19 patients.

Percutaneous left ventricular support for high-risk PCI and cardiogenic shock: who gets what?

2012 ◽  
Vol 13 (2) ◽  
pp. 101-105 ◽  
Author(s):  
Roshni Shah ◽  
Alexcis Thomson ◽  
Kimberly Atianzar ◽  
Keith Somma ◽  
Anilkumar Mehra ◽  
...  
Keyword(s):  
High Risk ◽  
Cardiogenic Shock ◽  
Left Ventricular ◽  
Ventricular Support

scholarly journals Culprit vessel: impact on short-term and long-term prognosis in patients with ST-elevation myocardial infarction

Open Heart ◽  
2018 ◽  
Vol 5 (2) ◽  
pp. e000852 ◽  
Author(s):  
Artin Entezarjou ◽  
Moman Aladdin Mohammad ◽  
Pontus Andell ◽  
Sasha Koul
Keyword(s):  
Myocardial Infarction ◽  
Heart Failure ◽  
High Risk ◽  
Left Ventricular ◽  
St Elevation Myocardial Infarction ◽  
Clinical Event ◽  
Left Ventricular Ejection ◽  
Increased Risk ◽  
St Elevation ◽  
The Impact

BackgroundST-elevation myocardial infarction (STEMI) occurs as a result of rupture of an atherosclerotic plaque in the coronary arteries. Limited data exist regarding the impact of culprit coronary vessel on hard clinical event rates. This study investigated the impact of culprit vessel on outcomes after primary percutaneous coronary intervention (PCI) of STEMI.MethodsA total of 29 832 previously cardiac healthy patients who underwent primary PCI between 2003 and 2014 were prospectively included from the Swedish Coronary Angiography and Angioplasty Registry and the Registry of Information and Knowledge about Swedish Heart Intensive care Admissions. Patients were stratified into three groups based on culprit vessel (right coronary artery (RCA), left anterior descending artery (LAD) and left circumflex artery (LCx)). The primary outcome was 1-year mortality. The secondary outcomes included 30-day and 5-year mortality, as well as heart failure, stroke, bleeding and myocardial reinfarction at 30 days, 1 year and 5 years. Univariable and multivariable analyses were done using Cox regression models.ResultsOne-year analyses revealed that LAD infarctions had the highest increased risk of death, heart failure and stroke compared with RCA infarctions, which had the lowest risk. Sensitivity analyses revealed that reduced left ventricular ejection fraction on discharge partially explained this increased relative risk in mortality. Furthermore, landmark analyses revealed that culprit vessel had no significant influence on 1-year mortality if a patient survived 30 days after myocardial infarction. Subgroup analyses revealed female sex and multivessel disease (MVD) as significant high-risk groups with respect to 1-year mortality.ConclusionsLAD and LCx infarctions had a relatively higher adjusted mortality rate compared with RCA infarctions, with LAD infarctions in particular being associated with an increased risk of heart failure, stroke and death. Culprit vessel had limited influence on mortality after 1 month. High-risk patient groups include LAD infarctions in women or with concomitant MVD.

scholarly journals P106: Systemic thrombolysis for suspected high-risk pulmonary embolism: a retrospective medical record review

CJEM ◽  
2018 ◽  
Vol 20 (S1) ◽  
pp. S94-S94
Author(s):  
A. Mulla ◽  
K. de Wit
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Major Bleeding ◽  
Treatment Guidelines ◽  
Demographic Variable ◽  
Univariate Analysis ◽  
Fibrinolytic Therapy ◽  
Moderate Risk ◽  
Systemic Thrombolysis ◽  
History Of

Introduction: Current treatment guidelines advocate for the aggressive management of both high-risk and subsets of moderate-risk pulmonary embolism (PE) with fibrinolytic therapy. However, there is limited evidence on the risks and benefits of fibrinolytic therapy in PE, with mortality improvement still to be proven. This study aimed to report the incidence of major bleeding and death after thrombolysis for PE. Methods: A health records review was performed on data from two hospitals between 2007 and 2017. Pharmacy identified all patients who had received either alteplase or tenecteplase. Trained abstractors reviewed each chart to determine the indication for thrombolytic therapy. Patients were included if they received systemic thrombolysis for diagnosed or presumed PE. Data was extracted on 30-day mortality, International Society of Thrombosis and Hemostasis defined major bleeding within 30 days, premorbid anticoagulant and antiplatelet prescription, age, sex, comorbidities, renal function, history of bleeding, type and dose of thrombolytic and category of PE (high or moderate risk). Results: 1534 patients were identified, of which 72 received systemic thrombolysis for PE. The median age was 57, 34 were male, 17 with a history of venous thrombosis and 12 with cancer. Fifty-four were classified as having high-risk PE, of whom 39 received cardiopulmonary resuscitation (CPR) when thrombolysis was administered. Formal confirmatory imagining for PE was obtained in only 23/39 patients who were in cardiac arrest. Eighteen patients were classified as moderate-risk PE. The incidence of major bleeding was 28/54 (52%, 95% CI 39-65%), and 3/18 (17%, 95% CI 6-39%) for the high and moderate risk groups respectively. There were 4 intracranial bleeds, all in the high-risk PE group. The only significant predictor of major bleeding was the need for CPR at the point of administration of the thrombolytic agent (OR 2.6, 95% CI 1.0-7.5, adjusted for age). Thirty-four patients died within 30 days (47%, 95% CI 36-59%), all in the high-risk PE group. Death was not associated with any demographic variable on univariate analysis. Death occurred in 28/39 (72%, 95%CI 56-83%) patients who received CPR and 6/33 (18%, 95% CI 9-34%) who did not. Conclusion: We found a high incidence of 30-day major bleeding and death following administration of thrombolysis for PE which will help inform future prognostic discussions in our institution.

scholarly journals Critically Ill Patients with Variable Heart Failure in Severe COVID-19 Disease: A Case Series

2021 ◽  
Vol 8 ◽  
Author(s):  
Joanne Michelle Gomez ◽  
Mary Potkonjak ◽  
Maria Isabel Planek ◽  
Prutha Lavani ◽  
Karolina Marinescu ◽  
...  
Keyword(s):  
Heart Failure ◽  
Pulmonary Embolism ◽  
Early Diagnosis ◽  
Cardiogenic Shock ◽  
Critically Ill ◽  
Case Series ◽  
Cardiovascular Effects ◽  
Massive Pulmonary Embolism ◽  
System Disorder ◽  
Obstructive Shock

COVID-19 disease, while primarily a respiratory disease, has proven itself a multi-system disorder with profound cardiovascular sequelae. In patients with SARS-CoV-2 infection, effective early diagnosis and management of concomitant cardiovascular manifestations of the disease are key to favorable outcomes. Here we present a case series of three patients with varied cardiovascular presentations of severe COVID-19 illness: cardiogenic shock from Takotsubo cardiomyopathy, arrhythmia in a patient with suspected hydroxychloroquine-associated cardiomyopathy, and right-sided heart failure with obstructive shock in the setting of massive pulmonary embolism. Through our experience, we aim to provide a better understanding of the unique spectrum of the cardiovascular effects of severe COVID-19 disease to guide management of the critically ill.

Abstract 13943: Hypertrophic Cardiomyopathy with Left Ventricular Apical Aneurysm Represents a High-Risk Subgroup Necessitating Aggressive Preventive Therapy: A Long-term Follow-Up Study

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Ethan J Rowin ◽  
Barry J Maron ◽  
Tammy S Haas ◽  
John R Lesser ◽  
Mark S Link ◽  
...  
Keyword(s):  
Heart Failure ◽  
Hypertrophic Cardiomyopathy ◽  
High Risk ◽  
Sudden Death ◽  
Left Ventricular ◽  
Increased Risk ◽  
Long Term Follow Up ◽  
Apical Aneurysm

Background: Increasing penetration of high spatial resolution cardiovascular magnetic resonance (CMR) imaging into routine cardiovascular practice has resulted in more frequent identification of a subset of hypertrophic cardiomyopathy (HCM) patients with thin-walled, scarred left ventricular (LV) apical aneurysms. Prior experience involved relatively small numbers of patients with short follow-up and therefore the risk associated with this subgroup remains incompletely defined. Therefore, we assembled a large HCM cohort with LV apical aneurysms and long-term follow-up in order to clarify clinical course and prognosis. Methods and Results: Of 2,400 HCM patients, 60 (2.5%) were identified by CMR with LV apical aneurysm, 24 to 86 years of age, including 19 (32%) <45 years old; 70% male, and followed for 5.6 ± 3.5 years. Over the follow-up period, 24 patients experienced 31 adverse disease-related complications including: appropriate implantable cardioverter-defibrillator discharge for VT/VF (n=11), received or listed for heart transplant (n=6), heart failure death (n=5), nonfatal thromboembolic events (n=4), resuscitated out-of-hospital cardiac arrest (n=3), and sudden death (n=2). In addition, an intracavitary thrombus was identified in the apical aneurysm in 9 patients without a thromboembolic history. Combined HCM-related death and aborted life threatening event rate was 8.6% per year, nearly 6-fold greater than the 1.5% annual mortality rate reported in the general HCM population. Conclusions: Patients with LV apical aneurysms represent a high-risk subgroup within the diverse HCM spectrum, associated with substantial increased risk for disease-related morbidity and mortality, including advanced heart failure, thromboembolic stroke and sudden death. Identification of this unique HCM phenotype should prompt consideration for primary prevention ICD, and anticoagulation for stroke prophylaxis.

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