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.

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.

scholarly journals Clinically inapparent right heart dysfunction is associated with reduced myofilament force development in coronary artery disease

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
C. Bening ◽  
V. L. Sales ◽  
K. Alhussini ◽  
D. Radakovic ◽  
R. Cris Benitez ◽  
...  
Keyword(s):  
Right Ventricular ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Pentraxin 3 ◽  
Force Measurements ◽  
Right Heart ◽  
Heart Dysfunction ◽  
Force Development ◽  
Skinned Fiber ◽  
Right Heart Dysfunction

Abstract Background Right ventricular dysfunction after CABG is associated with poor peri- and postoperative outcomes. We aimed to identify clinical and experimental predictors for preoperative inapparent right ventricular dysfunction and therefore hypothesized that reduced myofilament force development as well as altered levels of biomarkers might predict inapparent right ventricular dysfunction. Methods From 08/2016 to 02/2018, 218 patients scheduled for CABG were divided into two groups (TAPSE ≥ 20 mm, n = 178; TAPSE < 20 mm, n = 40). Baseline serum samples for biomarkers (Galectin, TGFß1, N Acyl-SDMA, Arginine, ADMA and Pentraxin-3), clinical laboratory and transthoracic echocardiographic parameters were evaluated. To examine the myocardial apparatus of the right ventricle intraoperative right auricular tissue was harvested for stepwise skinned fiber force measurements. Results Patients with TAPSE < 20 mm had a higher incidence of DM (55 vs. 34%, p = 0.018), preoperative AFib (43 vs. 16%, p < 0.001), reduced GFR (67 ± 18 vs. 77 ± 24 ml/min/1.73 m2, p = 0.013), larger LA area (22 ± 6 vs. 20 ± 5 cm2, p = 0.005) and reduced LVEF (50 vs. 55%, p = 0.008). Furthermore, higher serum ADMA (0.70 ± 0.13 vs. 0.65 ± 0.15 µmol/l, p = 0.046) and higher serum Pentraxin-3 levels (3371 ± 1068 vs. 2681 ± 1353 pg/dl, p = 0.004) were observed in these patients. Skinned fiber force measurements showed significant lower values at almost every step of calcium concentration (pCa 4.52 to pCa 5.5, p < 0.01 and pCa 5.75–6.0, p < 0.05). Multivariable analysis revealed DM (OR 2.53, CI 1.12–5.73, Euro Score II (OR 1.34, CI 1.02–1.78), preoperative AF (OR 4.86, CI 2.06–11.47), GFR (OR 7.72, CI 1.87–31.96), albumin (OR 1.56, CI 0.52–2.60), Pentraxin-3 (OR 19.68, CI 14.13–25.24), depressed LVEF (OR 8.61, CI 6.37–10.86), lower force values: (pCa 5.4; OR 2.34, CI 0.40–4.29 and pCa 5.2; OR 2.00, CI 0.39–3.60) as predictors for clinical inapparent right heart dysfunction. Conclusions These preliminary data showed that inapparent right heart dysfunction in CAD is already associated with reduced force development of the contractile apparatus.

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

Radiology ◽  
2012 ◽  
Vol 265 (1) ◽  
pp. 283-293 ◽  
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

scholarly journals Impella RP Support and Catheter-Directed Thrombolysis to Treat Right Ventricular Failure Caused by Pulmonary Embolism in 2 Patients

2018 ◽  
Vol 45 (3) ◽  
pp. 182-185 ◽  
Author(s):  
Mohamed Shokr ◽  
Ahmed Rashed ◽  
Ashraf Mostafa ◽  
Tamam Mohamad ◽  
Theodore Schreiber ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Massive Pulmonary Embolism ◽  
Left Ventricular ◽  
Right Ventricular Failure ◽  
Circulatory Support ◽  
Ventricular Failure ◽  
Ventricular Assist ◽  
Device Implantation ◽  
Catheter Directed Thrombolysis

Right ventricular failure secondary to pulmonary embolism is associated with morbidity and death. The Impella RP System has often been used for percutaneous mechanical circulatory support in patients with right ventricular failure from other causes, including myocardial infarction, cardiac surgery, and left ventricular assist device implantation. We report 2 cases of massive pulmonary embolism in which combined Impella RP use and ultrasound-assisted catheter-directed thrombolysis effectively treated shock caused by right ventricular failure and contributed to successful outcomes. To our knowledge, only one other patient with this indication had been treated with the Impella RP device.

scholarly journals Malnutrition, congestion and mortality in ambulatory patients with heart failure

Heart ◽  
2018 ◽  
Vol 105 (4) ◽  
pp. 297-306 ◽  
Author(s):  
Shirley Sze ◽  
Pierpaolo Pellicori ◽  
Jufen Zhang ◽  
Andrew L Clark
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Right Atrial ◽  
Left Ventricular Ejection ◽  
Right Heart ◽  
Heart Dysfunction ◽  
Nutritional Risk Index ◽  
Ambulatory Patients ◽  
Right Heart Dysfunction

BackgroundIn patients with chronic heart failure (CHF), malnutrition might be related to right heart dysfunction and venous congestion, which predispose to bowel oedema and malabsorption, thereby leading to malnutrition. We explored the relation between congestion, malnutrition and mortality in a large cohort of ambulatory patients with CHF.MethodsWe assessed malnutrition using the Geriatric Nutritional Risk Index (GNRI). Congestion was defined by echocardiography (raised right atrial pressure (RAP)=dilated inferior vena cava≥21 mm/raised pulmonary artery systolic pressure (PAsP)=transtricuspid gradient of ≥36 mm Hg/right ventricular systolic dysfunction (RVSD)=tricuspid annular plane systolic excursion <17 mm).ResultsOf the 1058 patients enrolled, CHF was confirmed in 952 (69% males, median age 75 (IQR: 67–81) years, median N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) 1141 (IQR: 465–2562) ng/L). 39% had HF with -reduced ejection fraction (left ventricular ejection fraction, LVEF <40%) and 61% had HF with normal (HeFNEF, LVEF ≥40% and NT-pro-BNP >125 ng/L) ejection fraction. Overall, 14% of patients were malnourished (GNRI ≤98). 35% had raised RAP, 23% had raised PAsP and 38% had RVSD. Congestion was associated with malnutrition. During a median follow-up of 1683 days (IQR: 1096–2230 days), 461 (44%) patients died. Malnutrition was an independent predictor of mortality. Patients who were malnourished with both RVSD and increased RAP had much worse outcome compared with non-malnourished patients without RVSD who had normal RAP.ConclusionMalnutrition and congestion are modestly correlated and each is independently associated with increased mortality in patients with CHF. Patients with HF with both malnutrition and congestion as evidenced by right heart dysfunction should be managed with additional vigilance.

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