Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

Download Full-text

Transcriptional profile of right ventricular tissue during acute pulmonary embolism in rats

Physiological Genomics ◽

10.1152/physiolgenomics.00261.2007 ◽

2008 ◽

Vol 34 (1) ◽

pp. 101-111 ◽

Cited By ~ 25

Author(s):

John Zagorski ◽

Nina Sanapareddy ◽

Michael A. Gellar ◽

Jeffrey A. Kline ◽

John A. Watts

Keyword(s):

Pulmonary Embolism ◽

Right Ventricular ◽

Dna Microarrays ◽

Acute Pulmonary Embolism ◽

Inflammatory Responses ◽

The United States ◽

Cardiovascular Death ◽

Oxidative Enzymes ◽

Cxc Chemokine ◽

Pathway Analyses

Acute pulmonary embolism (PE) is the third leading cause of cardiovascular death in the United States. Moderate to severe PE can cause pulmonary arterial hypertension (PH) with resultant right ventricular (RV) heart damage. The mechanisms leading to RV failure after PE are not well defined, although it is becoming clear that PH-induced inflammatory responses are involved. We previously demonstrated profound neutrophil-mediated inflammation and RV dysfunction during PE that was associated with increased expression of several chemokine genes. However, a complete assessment of transcriptional changes in RVs during PE is still lacking. We have now used DNA microarrays to assess the alterations in gene expression in RV tissue during acute PE/PH in rats. Key results were confirmed with real-time RT-PCR. Nine CC-chemokine genes (CCL-2, -3, -4, -6, -7, -9, -17, -20, -27), five CXC-chemokine genes (CXCL-1, -2, -9, -10, -16), and the receptors CCR1 and CXCR4 were upregulated after 18 h of moderate PE, while one C-chemokine (XCL-1) and one CXC-chemokine (CXCL-12) were downregulated. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway analyses indicated increased expression of many inflammatory genes. There was also a major shift in the expression of components of metabolic pathways, including downregulation of fatty acid transporters and oxidative enzymes, a change in glucose transporters, and upregulation of stretch-sensing and hypoxia-inducible transcription factors. This pattern suggests an extensive shift in cardiac physiology favoring the expression of the “fetal gene program.”

Download Full-text

Ultrasound-Accelerated Thrombolysis in High-Risk Perioperative Pulmonary Embolism: Two Case Reports and Review of Literature

10.21203/rs.3.rs-82629/v1 ◽

2020 ◽

Author(s):

Götz Schmidt ◽

Fabian Edinger ◽

Christian Koch ◽

Matthias Wolff ◽

Christoph Biehl ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Major Bleeding ◽

Intracranial Haemorrhage ◽

Case Reports ◽

Haemodynamic Instability ◽

Pulmonary Embolectomy ◽

Systemic Thrombolysis ◽

Catheter Directed Thrombolysis ◽

Randomised Controlled

Abstract Background: Treatment of high-risk pulmonary embolism (PE) in perioperative patients remains challenging. Systemic thrombolysis is associated with a high risk of major bleedings and intracranial haemorrhage. High mortality rates are reported for open pulmonary embolectomy. Therefore, postoperative surgical patients may benefit substantially from catheter-directed ultrasound-accelerated thrombolysis (USAT).Case summary: We report two cases of high-risk perioperative PE. Both patients developed severe haemodynamic instability leading to cardiac arrest. After the implantation of a veno-arterial extracorporeal membrane oxygenation (ECMO), they were both successfully treated with USAT. Adequate improvement of right ventricular function was achieved; thus, ECMO could be successfully weaned after three and four days, respectively. Both patients showed favourable outcomes and could be discharged to rehabilitation. Discussion: The current European guideline on treatment of PE offers no specific therapies for perioperative patients with high-risk PE. However, systemic thrombolysis is often excluded due to the perioperative setting and the risk of major bleeding. Catheter-directed thrombolysis was shown to utilise less thrombolytic agent while obtaining comparable thrombolytic effects. The risk for major bleeding (including intracranial haemorrhage) is also significantly lowered. Conclusion: Further prospective randomised controlled trials are necessary to determine the value of USAT treatment of high-risk PE in perioperative patients.

Download Full-text

Emergent Surgical Pulmonary Embolectomy in a Pregnant Woman: Case Report and Literature Review

Texas Heart Institute Journal ◽

10.14503/thij-12-2692 ◽

2014 ◽

Vol 41 (2) ◽

pp. 188-194 ◽

Cited By ~ 7

Author(s):

Giovanni Saeed ◽

Michael Möller ◽

Jörg Neuzner ◽

Rainer Gradaus ◽

Werner Stein ◽

...

Keyword(s):

Pulmonary Embolism ◽

Acute Pulmonary Embolism ◽

Pulmonary Arteries ◽

The United States ◽

Massive Pulmonary Embolism ◽

Healthy Male ◽

Pulmonary Embolectomy ◽

Mother And Child ◽

Pregnancy And Delivery ◽

Male Neonate

Acute pulmonary embolism is a leading cause of death during pregnancy and delivery in the United States. We describe the case of a 25-year-old woman who presented in car-diogenic shock in week 38 of her first pregnancy. After the emergent cesarean delivery of a healthy male neonate, the mother underwent immediate surgical pulmonary embolec-tomy. We confirmed the diagnosis of pulmonary embolism intraoperatively by means of transesophageal echocardiography and removed large clots from the patient's pulmonary arteries. Mother and child were doing well, 27 months later. In addition to presenting our patient's case, we discuss the other relevant reports and the options for treating massive pulmonary embolism during pregnancy.

Download Full-text

Successful use of a new hand-held ECMO system in cardiopulmonary failure and bleeding shock after thrombolysis in massive post-partal pulmonary embolism

Perfusion ◽

10.1177/0267659109106295 ◽

2009 ◽

Vol 24 (1) ◽

pp. 49-50 ◽

Cited By ~ 20

Author(s):

M Arlt ◽

A Philipp ◽

I Iesalnieks ◽

R Kobuch ◽

BM Graf

Keyword(s):

Pulmonary Embolism ◽

Life Support ◽

Rapid Onset ◽

Massive Pulmonary Embolism ◽

Massive Bleeding ◽

Spontaneous Circulation ◽

Systemic Blood Flow ◽

Pulmonary Embolectomy ◽

Systemic Thrombolysis ◽

Cardiopulmonary Failure

Massive pulmonary embolism (PE) leads to cardiogenic shock and is associated with mortality rates of up to 75%.1 We report on a 27-year-old mother in childbirth who developed a massive post-partal PE and cardiac arrest. Despite mechanical resuscitation, return of spontaneous circulation (ROSC) could not be achieved. After systemic thrombolysis, ROSC returned, but cardiopulmonary failure was persisting, complicated by massive bleeding shock. By using a newly developed, hand-held ECMO system, systemic blood flow and oxygenation were restored and emergency medical services for advanced surgical treatment (hysterectomy and pulmonary embolectomy) were possible. The patient recovered completely. We assume that this newly developed hand-held ECMO device enables rapid onset mechanical life support and improves the prognosis of patients in fatal conditions.

Download Full-text

Catheter-Directed Thrombolysis for Submassive Pulmonary Embolism

Seminars in Interventional Radiology ◽

10.1055/s-0038-1642041 ◽

2018 ◽

Vol 35 (02) ◽

pp. 122-128 ◽

Cited By ~ 3

Author(s):

Matthew Chiarello ◽

Akhilesh Sista

Keyword(s):

Pulmonary Embolism ◽

The United States ◽

Similar Efficacy ◽

Major Hemorrhage ◽

Systemic Thrombolysis ◽

Clinical Endpoints ◽

Catheter Directed Thrombolysis ◽

Right Ventricular Strain ◽

Submassive Pulmonary Embolism

AbstractAcute pulmonary embolism (PE) is a leading cause of morbidity and mortality in the United States. PE associated with right ventricular strain, termed submassive or intermediate-risk PE, is associated with an increased rate of clinical deterioration and short-term mortality. Trials have demonstrated systemic thrombolytics may improve patient outcomes, but they carry a risk of major hemorrhage. Catheter-directed thrombolysis (CDT) may offer similar efficacy to and a lower risk of catastrophic hemorrhage than systemic thrombolysis. Three prospective trials have evaluated CDT for submassive PE; ULTIMA, SEATTLE II, and PERFECT. These trials provide evidence that CDT may improve radiographic efficacy endpoints in submassive PE with acceptable rates of major hemorrhage. However, the lack of clinical endpoints, long-term follow-up, and adequate sample size limit their generalizability. Future trials should be adequately powered and controlled so that the short- and long-term effectiveness and safety of CDT can be definitively determined.

Download Full-text

Aggressive Therapy for Acute Pulmonary Embolism: Systemic Thrombolysis and Catheter-Directed Approaches

Seminars in Respiratory and Critical Care Medicine ◽

10.1055/s-0040-1722291 ◽

2021 ◽

Author(s):

Thomas M. Todoran ◽

Bradley Petkovich

Keyword(s):

Pulmonary Embolism ◽

Clinical Evidence ◽

The United States ◽

Population Based ◽

Systemic Thrombolysis ◽

Stroke Population ◽

Catheter Directed Thrombolysis ◽

Surgical Embolectomy ◽

Contemporary Management ◽

Acute Pe

AbstractVenous thromboembolism (VTE) is the third most common cause of cardiovascular disease after myocardial infarction and stroke. Population-based studies estimate that up to 94,000 new cases of pulmonary embolism (PE) occur in the United States annually with an increasing incidence with age. Mortality from PE is the greatest in the first 24 hours, with a decreased survival extending out 3 months. Thus, acute PE is a potentially fatal illness if not recognized and treated in a timely manner. Contemporary management includes systemic anticoagulation, thrombolysis, catheter-based procedures, and surgical embolectomy. This article reviews current clinical evidence and societal guidelines for the use of systemic and catheter-directed thrombolysis for treatment of acute PE.

Download Full-text

Effects of catheter-directed therapy for pulmonary embolism on pulmonary artery systolic pressure and PaO2/FiO2

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.194 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

M Muzzio ◽

A Rossini ◽

D Costa ◽

L Garcia Iturralde ◽

C Gonzalez ◽

...

Keyword(s):

Pulmonary Embolism ◽

High Risk ◽

Pulmonary Artery ◽

Systolic Pressure ◽

Bleeding Risk ◽

Cardiovascular Death ◽

Pulmonary Artery Systolic Pressure ◽

Systemic Thrombolysis ◽

Funding Sources ◽

High Bleeding Risk

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulmonary embolism (PE) is the third global cause of cardiovascular death. Treatment of high-risk cases and selected intermediate-risk cases is based on systemic thrombolysis, which can be inconvenient in patients with a contraindications for thrombolysis. Catheter-directed therapies are emerging as an alternative for treatment when there is an increased bleeding risk. Methods One-center retrospective study of patients with high or intermediate-high risk PE with contraindications for systemic thrombolysis. Catheter directed rheolytic thrombectomy or mechanical thrombectomy was performed, assessing its effect on clinical variables, pulmonary artery systolic pressure (PASP), PaO2/FiO2, and the occurrence of complications. Results In 12 patients with PE treated with catheter-directed therapy, we observed a mean increase of the PaO2/FiO2 of 62 mm Hg (p = 0.013), as well mean reduction in the PASP of 13 mm Hg (p < 0.001), as can be observed in the figure. As complications, there was one case of hemoptysis, and two of hemolysis, with an in-hospital mortality of 16.7%. Conclusion Catheter-directed therapy in patients with high or intermediate-high risk PE is a feasible option when there are contraindications for thrombolysis or there is a high bleeding risk. It has been shown to improve surrogate endpoints as PASP and right to left ventricle ratio in other studies, although data on mortality from a randomized trial is lacking. Abstract Figure. Gardner-Altman plots.

Download Full-text