Successful Thrombolysis for High-Risk Pulmonary Embolism in a Patient With Extensive Pemphigus Vulgaris

Summary: COVID-19 is a recently identified illness that is associated with thromboembolic events. We report a case of pulmonary embolism in a patient with COVID-19, treated by catheter directed thrombectomy. A 57 year old patient presented to the emergency center with severe COVID-19 symptoms and developed massive pulmonary embolism. The patient was treated with catheter directed thrombolysis (CDT) and recovered completely. Coagulopathy associated with COVID-19 is present in all severe cases and is a dynamic process. We describe a case of massive/high risk pulmonary embolism, in a patient with COVID-19 receiving full anticoagulation, who was treated by percutaneous intervention. CDT can be an additional therapeutic option in patients with COVID-19 and pulmonary embolism that present with rapid clinical collapse.

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

European Heart Journal - Case Reports ◽

10.1093/ehjcr/ytaa388 ◽

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.

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Renal function improves mortality prediction in acute pulmonary embolism: results of a multicentre cohort study with external validation in the RIETE registry

European Heart Journal ◽

10.1093/ehjci/ehaa946.2239 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

R Chopard ◽

D Jimenez ◽

G Serzian ◽

F Ecarnot ◽

N Falvo ◽

...

Keyword(s):

Pulmonary Embolism ◽

Renal Function ◽

High Risk ◽

Renal Dysfunction ◽

External Validation ◽

Mortality Prediction ◽

Model Fit ◽

Funding Source ◽

Risk Of Death ◽

Acute Pe

Abstract Background Renal dysfunction may influence outcomes after pulmonary embolism (PE). We determined the incremental value of adding renal function impairment (estimated glomerular filtration rate, eGFR <60 ml/min/1.73m2) on top of the 2019 ESC prognostic model, for the prediction of 30-day all-cause mortality in acute PE patients from a prospective, multicenter cohort. Methods and results We identified which of three eGFR formulae predicted death most accurately. Changes in global model fit, discrimination, calibration and net reclassification index (NRI) were evaluated with addition of eGFR. We prospectively included consecutive adult patients with acute PE diagnosed as per ESC guidelines. Among 1,943 patients, (mean age 67.3±17.1, 50.4% women), 107 (5.5% (95% CI 4.5–6.5%)) died during 30-day follow-up. The eGFRMDRD4 formula was the most accurate for prediction of death. The observed mortality rate was higher for intermediate-low risk (OR 1.8, 95% CI 1.1–3.4) and high-risk PE (OR 10.3, 95% CI 3.6–17.3), and 30-day bleeding was significantly higher (OR 2.1, 95% CI 1.3–3.5) in patients with vs without eGFRMDRD4 <60 ml/min/1.73m2. The addition of eGFRMDRD4 information improved model fit, discriminatory capacity, and calibration of the ESC models. NRI was significantly improved (p<0.001), with 18% reclassification of predicted mortality, specifically in intermediate and high-risk PE. External validation using data from the RIETE registry confirmed our findings (Table). Conclusion Addition of eGFRMDRD4-derived renal dysfunction on top of the ESC prognostic algorithm yields significant reclassification of risk of death in intermediate and high-risk PE. Impact on therapy remains to be determined. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): BMS-Pfizer Alliance, Bayer Healthcare

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Right Atrial Thrombosis and Pulmonary Embolism: A Narrative Review

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0040-1718399 ◽

2020 ◽

Vol 46 (08) ◽

pp. 895-907

Author(s):

Nina D. Anfinogenova ◽

Oksana Y. Vasiltseva ◽

Alexander V. Vrublevsky ◽

Irina N. Vorozhtsova ◽

Sergey V. Popov ◽

...

Keyword(s):

Atrial Fibrillation ◽

Pulmonary Embolism ◽

High Risk ◽

Transesophageal Echocardiography ◽

Three Dimensional ◽

Right Atrial ◽

Treatment Protocols ◽

High Risk Patients ◽

Risk Patients ◽

The Right

AbstractPrompt diagnosis of pulmonary embolism (PE) remains challenging, which often results in a delayed or inappropriate treatment of this life-threatening condition. Mobile thrombus in the right cardiac chambers is a neglected cause of PE. It poses an immediate risk to life and is associated with an unfavorable outcome and high mortality. Thrombus residing in the right atrial appendage (RAA) is an underestimated cause of PE, especially in patients with atrial fibrillation. This article reviews achievements and challenges of detection and management of the right atrial thrombus with emphasis on RAA thrombus. The capabilities of transthoracic and transesophageal echocardiography and advantages of three-dimensional and two-dimensional echocardiography are reviewed. Strengths of cardiac magnetic resonance imaging (CMR), computed tomography, and cardiac ventriculography are summarized. We suggest that a targeted search for RAA thrombus is necessary in high-risk patients with PE and atrial fibrillation using transesophageal echocardiography and/or CMR when available independently on the duration of the disease. High-risk patients may also benefit from transthoracic echocardiography with right parasternal approach. The examination of high-risk patients should involve compression ultrasonography of lower extremity veins along with the above-mentioned technologies. Algorithms for RAA thrombus risk assessment and protocols aimed at identification of patients with RAA thrombosis, who will potentially benefit from treatment, are warranted. The development of treatment protocols specific for the diverse populations of patients with right cardiac thrombosis is important.

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Echocardiographic signs of successful thrombolysis in a pulmonary embolism and COVID-19 pneumonia

Journal of Echocardiography ◽

10.1007/s12574-021-00517-w ◽

2021 ◽

Author(s):

Julio C. Sauza-Sosa ◽

Jorge Mendoza-Ramirez ◽

Carlos N. Velazquez-Gutierrez ◽

Erika L. De la Cruz-Reyna ◽

Jorge Fernandez-Tapia

Keyword(s):

Pulmonary Embolism ◽

Successful Thrombolysis

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Catheter-directed low-dose fibrinolysis infusion for treat acute intermediate-high risk pulmonary embolism

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.196 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

MM Martin Cabeza ◽

MJ Garcia Gonzalez ◽

P Jorge Perez ◽

A Sanchez-Grande Flecha ◽

R Munoz Rodriguez ◽

...

Keyword(s):

Pulmonary Embolism ◽

Pulmonary Hypertension ◽

High Risk ◽

Low Dose ◽

Therapeutic Option ◽

Bleeding Complications ◽

Common Disease ◽

Effective Treatment Option ◽

Femoral Access ◽

Rv Function

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Intermediate-high risk (IHR) Pulmonary Embolism (PE) are a common disease witch could have a high mortality. Anticoagulation remains the first therapeutic option, but Catheter-directed therapies are being investigated as a safe and effective treatment option. PURPOSE To evaluate the safety and efficacy of Catheter-directed low-dose fibrinolysis infusion to treat IHR-PE. METHODS Retrospective analysis of 16 patients IHR-PE treated. After performing Right catheterization (RC) and angiogram, Pigtail catheters were located for intrapulmonary infusion of Alteplase 1mg/h/catheter for 24 h (25-30mg/day). Baseline and clinical characteristics, inicial and evolutive echocardiography, also clinical evaluation and echocardiography 6 months after discharge were evaluated. RESULTS The majority were women (11) and obese (93.8%), aged 22-74 years with cardiovascular risk factors: 5 hypertension, 3 Dyslipidemia, 2 smokers and 3 severe CKD . At admission 11 patients consulted for dyspnea and 5 for syncope; all were hemodynamic stable. 68.8% presented respiratory failure. All had bilateral PE (angiography) and elevation of Nt-proBNP and troponins. The echocardiographic at admission, and its evolution are shown in Table 1. The invasive measurement of pulmonary hypertension (PH) reflected greater severity than the estimated by echo: 5 (31.3%) Severe PH, 5 (31.3%) Moderate PH and 2 (12.5%) mild PH. At discharge all presented a decrease in PH and 15 (93.8%) improved RV function. 2 patients suffered bleeding complications (relation with femoral access): 1 not severe, 1 severe without mortality; none suffered intracranial hemorrhage. In the evaluation at 6-months: 13 patients (81.3%) where on functional Class I and without PH, 3 patients (18.8%) where in Class II and with mild-PH. CONCLUSION In short-term follow-up, intrapulmonary low-dose fibrinolysis reduces PA pressures and improves RV function, without an increased bleeding complications, especially if femoral access is avoided. However impact on long-term remains unclear. Table 1: Echocardiography evolution.RV function admissionNormal Function1 (6.3%)Mild Dysfunction9 (56.3%)Moderate Dysfunction6 (37.5%)RV Dilatation admissionDilatation 16 (100%)Not dilatation 0 (0%)PH Degree admissionMild PH6 (37.5%)Moderate PH5 (31.3%)Severe PH5 (31.3%)PH Degree 24h-postNot PH1 (6.3%)Mild PH10 (62.5%)Moderate/severe PH5 (31.3%)Improvement RV 24h-postYes14 (87.5%)Not2 (12.5%)RV function dischargeNormal Function16 (100%)Mild Dysfunction0 (0%)Moderate Dysfunction0 (0%)RV Dilatation dischargeDilatation 5 (31.3%)Not dilatation 11 (68.8%)PH Degree dischargeNot PH 9 (56.3%)Mild PH7 (43.8%)Moderate/severe PH0 (0%)RV Right Ventricular; PH: Pulmonary Hypertension,

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CRT-300.08 High-risk Pulmonary Embolism Thrombectomy Using 8fr Judkins Right Guiding Coronary Catheter (Urgent, Cheaper And Feasible)

JACC Cardiovascular Interventions ◽

10.1016/j.jcin.2016.12.149 ◽

2017 ◽

Vol 10 (3) ◽

pp. S42

Author(s):

Luis Enrique Berumen Dominguez ◽

Hugo Gutierrez Leonard ◽

Anton Meneses Bonilla ◽

Ricardo Aguilar-oliva

Keyword(s):

Pulmonary Embolism ◽

High Risk

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Early, real-world experience with direct oral anticoagulants in the treatment of intermediate-high risk acute pulmonary embolism

Revista Portuguesa de Cardiologia (English Edition) ◽

10.1016/j.repce.2017.11.003 ◽

2017 ◽

Vol 36 (11) ◽

pp. 801-806

Author(s):

Sónia Martins Santos ◽

Susana Cunha ◽

Rui Baptista ◽

Sílvia Monteiro ◽

Pedro Monteiro ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Real World ◽

Acute Pulmonary Embolism ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants

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Forty-One-Year-Old Man with Pulmonary Embolism 5 Months After COVID-19

Clinical Medicine Insights Circulatory Respiratory and Pulmonary Medicine ◽

10.1177/1179548420986659 ◽

2021 ◽

Vol 15 ◽

pp. 117954842098665

Author(s):

Muhanad Taha ◽

Paul Nguyen ◽

Aditi Sharma ◽

Mazen Taha ◽

Lobelia Samavati

Keyword(s):

Risk Factors ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

High Risk ◽

Venous Thrombosis ◽

Case Summary ◽

One Year

Background: Hypercoagulation is one of the striking features of COVID-19. Patients hospitalized with COVID-19 are at high risk for venous thromboembolism. However, it is unknown if the risk for venous thromboembolism persists after discharge. Case Summary: We report a case with pulmonary embolism 5 months after COVID-19. No risk factors for venous thrombosis have been identified. Conclusion: In COVID-19 related hospitalization, large studies are needed to identify the risk of venous thromboembolism after discharge.

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In-Hospital Mortality and Related Outcomes for Elevated Risk Acute Pulmonary Embolism Treated With Mechanical Thrombectomy Versus Routine Care

Journal of Intensive Care Medicine ◽

10.1177/08850666211036446 ◽

2021 ◽

pp. 088506662110364

Author(s):

Jennifer R. Buckley ◽

Brandt C. Wible

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Length Of Stay ◽

Hospital Mortality ◽

Routine Care ◽

Hospital Length ◽

Elevated Risk ◽

Hospital Length Of Stay ◽

Icu Length Of Stay

Purpose To compare in-hospital mortality and other hospitalization related outcomes of elevated risk patients (Pulmonary Embolism Severity Index [PESI] score of 4 or 5, and, European Society of Cardiology [ESC] classification of intermediate-high or high risk) with acute central pulmonary embolism (PE) treated with mechanical thrombectomy (MT) using the Inari FlowTriever device versus those treated with routine care (RC). Materials and Methods Retrospective data was collected of all patients with acute, central PE treated at a single institution over 2 concurrent 18-month periods. All collected patients were risk stratified using the PESI and ESC Guidelines. The comparison was made between patients with acute PE with PESI scores of 4 or 5, and, ESC classification of intermediate-high or high risk based on treatment type: MT and RC. The primary endpoint evaluated was in-hospital mortality. Secondary endpoints included intensive care unit (ICU) length of stay, total hospital length of stay, and 30-day readmission. Results Fifty-eight patients met inclusion criteria, 28 in the MT group and 30 in the RC group. Most RC patients were treated with systemic anticoagulation alone (24 of 30). In-hospital mortality was significantly lower for the MT group than for the RC group (3.6% vs 23.3%, P < .05), as was the average ICU length of stay (2.1 ± 1.2 vs 6.1 ± 8.6 days, P < .05). Total hospital length of stay and 30-day readmission rates were similar between MT and RC groups. Conclusion Initial retrospective comparison suggests MT can improve in-hospital mortality and decrease ICU length of stay for patients with acute, central PE of elevated risk (PESI 4 or 5, and, ESC intermediate-high or high risk).

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