scholarly journals Case Report: Successful revascularization in massive pulmonary embolism with a large protruding thrombus and dilated cardiomyopathy

F1000Research ◽  
2021 ◽  
Vol 10 ◽  
pp. 13
Author(s):  
Hendri Susilo ◽  
Rerdin Julario ◽  
Citrawati Dyah Kencono Wungu
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Right Ventricular ◽  
Dilated Cardiomyopathy ◽  
Acute Pulmonary Embolism ◽  
Systolic Function ◽  
Vena Cava ◽  
Massive Pulmonary Embolism ◽  
Left Ventricular ◽  
Ventricular Afterload

Pulmonary embolism is a potentially life-threatening condition. Despite advances in diagnostics, lack of consensus and delays in determining the diagnosis of pulmonary embolism are still important problems. We report the diagnosis and management of a 37-year-old man suffering from massive pulmonary embolism, a large protruding thrombus, and dilated cardiomyopathy. Echocardiography showed dilatation of all cardiac chambers, a large protruding thrombus in the right atrium to the inferior vena cava, impaired left and right ventricular systolic function, and global hypokinetic of the left ventricle with eccentric left ventricular hypertrophy. A thoracic computerized tomography scan showed pulmonary embolism with infarction. The patient’s blood pressure was 60/40 mmHg and heart rate was 110 bpm. The patient was diagnosed with high-risk acute pulmonary embolism. We gave him hemodynamic support and reperfusion therapy with a loading dose of 250,000 units of Streptokinase followed by 100,000 units/hour for 24 hours. After revascularization, the patient's hemodynamic condition improved. The diagnosis of acute pulmonary embolism is based on clinical symptoms, hemodynamic changes, or radiological examination. Unstable hemodynamic underlies high-risk stratification. Hypotension or shock results from obstruction of the pulmonary artery which causes increased right ventricular afterload and acute right ventricular dysfunction. Reperfusion with thrombolysis therapy could provide good outcomes in this patient. Prolonged anticoagulation should be given to prevent the recurrence of venous thromboembolism.

scholarly journals Case Report: Successful revascularization in massive pulmonary embolism with a large protruding thrombus and dilated cardiomyopathy

F1000Research ◽  
2021 ◽  
Vol 10 ◽  
pp. 13
Author(s):  
Hendri Susilo ◽  
Rerdin Julario ◽  
Citrawati Dyah Kencono Wungu
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Right Ventricular ◽  
Dilated Cardiomyopathy ◽  
Acute Pulmonary Embolism ◽  
Systolic Function ◽  
Vena Cava ◽  
Massive Pulmonary Embolism ◽  
Left Ventricular ◽  
Ventricular Afterload

Pulmonary embolism is a potentially life-threatening condition. Despite advances in diagnostics, lack of consensus and delays in determining the diagnosis of pulmonary embolism are still important problems. We report the diagnosis and management of a 37-year-old man suffering from massive pulmonary embolism, a large protruding thrombus, and dilated cardiomyopathy. Echocardiography showed dilatation of all cardiac chambers, a large protruding thrombus in the right atrium to the inferior vena cava, impaired left and right ventricular systolic function, and global hypokinetic of the left ventricle with eccentric left ventricular hypertrophy. A thoracic computerized tomography scan showed pulmonary embolism with infarction. The patient’s blood pressure was 60/40 mmHg and heart rate was 110 bpm. The patient was diagnosed with high-risk acute pulmonary embolism. We gave him hemodynamic support and reperfusion therapy with a loading dose of 250,000 units of Streptokinase followed by 100,000 units/hour for 24 hours. After revascularization, the patient's hemodynamic condition improved. The diagnosis of acute pulmonary embolism is based on clinical symptoms, hemodynamic changes, or radiological examination. Unstable hemodynamic underlies high-risk stratification. Hypotension or shock results from obstruction of the pulmonary artery which causes increased right ventricular afterload and acute right ventricular dysfunction. Reperfusion with thrombolysis therapy could provide good outcomes in this patient. Prolonged anticoagulation should be given to prevent the recurrence of venous thromboembolism.

A novel echocardiographic parameter for assessment of right ventricular function in acute pulmonary embolism: an experimental study

2019 ◽  
Author(s):  
Decai Zeng ◽  
Ji Wu ◽  
Hui Chen ◽  
Ying Tan ◽  
Xueyu Che ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Autologous Blood ◽  
Left Ventricular ◽  
Control Group ◽  
Tei Index ◽  
Significant Difference ◽  
Acute Pe ◽  
Rv Function

Abstract Background Right ventricular (RV) dysfunction played a decisive role in clinical management and associated with poor prognosis in acute pulmonary embolism (PE). It still remains challenging to estimate RV function accurately for the reason of complex structure and geometry. The present study aimed to determine the value of right ventricular outflow tract systolic excursion (RVOT-SE) in evaluating RV function in an animal model with acute PE. Methods Thirty-three healthy New Zealand rabbits were randomly assigned to massive thrombus group, sub-massive thrombus group and control group, 11 rabbits per group. The acute PE model was established by intravenous infusion of autologous blood clots. After 1h of thrombus injection, transthoracic echocardiography was performed to assess RV function in all rabbits. Results The acute PE model was successfully made in 18 rabbits (massive thrombus group, n = 8; sub-massive thrombus group n = 10). Right/left ventricular end-diastolic diameter (RV/LV) ratio and RV myocardial performance (Tei) index were significantly increased, while RV fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE) and RVOT_SE were reduced in massive thrombus group. The value of RVOT-SE and RVFAC in sub-massive thrombus group decreased significantly compared with control group (P < 0.05). But there was no significant difference in RV/LV, TAPSE and Tei index (P > 0.05). ROC analysis showed that RVOT-SE had high sensitivity (94.4%) and specificity (72.7%) in identifying RV dysfunction in acute PE. The area under the ROC curve (AUC) for combined TAPSE and RVOT-SE was greater than that of TAPSE or RVOT-SE alone (AUC= 0.962, P < 0.01). Conclusion RV function in acute PE is significantly decreased, which is closely related to the size of embolus. RVOT_SE is a simple and highly distinctive parameter in identifying RV dysfunction and tends to be superior to conventional parameters in acute PE. The combination of RVOT-SE and TAPSE can further improve the diagnostic accuracy of acute PE.

scholarly journals Risk stratification in normotensive acute pulmonary embolism patients: focus on the intermediate–high risk subgroup

2019 ◽  
Vol 9 (4) ◽  
pp. 279-285 ◽  
Author(s):  
Ana Rita Santos ◽  
Pedro Freitas ◽  
Jorge Ferreira ◽  
Afonso Oliveira ◽  
Mariana Gonçalves ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
High Risk ◽  
Risk Stratification ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Ventricular Dysfunction ◽  
Right Ventricular Dysfunction ◽  
Cardiac Biomarkers ◽  
Cardiac Biomarker ◽  
Imaging Signs

Background: Patients with acute pulmonary embolism are at intermediate–high risk in the presence of imaging signs of right ventricular dysfunction plus one or more elevated cardiac biomarker. We hypothesised that intermediate–high risk patients with two elevated cardiac biomarkers and imaging signs of right ventricular dysfunction have a worse prognosis than those with one cardiac biomarker and imaging signs of right ventricular dysfunction. Methods: We analysed the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction in 525 patients with intermediate risk pulmonary embolism (intermediate-high risk = 237) presenting at the emergency department in two centres. Studied endpoints were composites of all-cause mortality and/or rescue thrombolysis at 30 days (primary endpoint; n=58) and pulmonary embolism-related mortality and/or rescue thrombolysis at 30 days (secondary endpoint; n=40). Results: Patients who experienced the primary endpoint showed a higher proportion of elevated troponin (47% vs. 76%, P<0.001), elevated N-terminal pro-brain natriuretic peptide (67% vs. 93%, P<0.001) and imaging signs of right ventricular dysfunction (47% vs. 80%, P<0.001). Multivariate analysis revealed N-terminal pro-brain natriuretic peptide (hazard ratio (HR) 3.6, 95% confidence interval (CI) 1.3–10.3; P=0.015) and imaging signs of right ventricular dysfunction (HR 2.8, 95% CI 1.5–5.2; P=0.001) as independent predictors of events. In the intermediate–high risk group, patients with two cardiac biomarkers performed worse than those with one cardiac biomarker (HR 3.3, 95% CI 1.8–6.2; P=0.003). Conclusions: Risk stratification in normotensive pulmonary embolism should consider the cumulative presence of cardiac biomarkers and imaging signs of right ventricular dysfunction, especially in the intermediate–high risk subgroup.

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.

Inhaled nitric oxide has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute pulmonary embolism

2020 ◽  
pp. 204887262091871 ◽  
Author(s):  
Anders Kramer ◽  
Christian Schmidt Mortensen ◽  
Jacob Gammelgaard Schultz ◽  
Mads Dam Lyhne ◽  
Asger Andersen ◽  
...  
Keyword(s):  
Nitric Oxide ◽  
Pulmonary Embolism ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Porcine Model ◽  
Inhaled Nitric Oxide ◽  
Intermediate Risk ◽  
Ventricular Afterload ◽  
Pulmonary Vasodilator ◽  
Acute Pe

Background Inhaled nitric oxide (iNO) effectively reduces right ventricular afterload when administered in the immediate phase of acute pulmonary embolism (PE) in preclinical animal models. In a porcine model of intermediate-risk PE, we aimed to investigate whether iNO has pulmonary vasodilator efficacy both in the immediate and prolonged phase of acute PE. Methods Anesthetized pigs ( n = 18) were randomized into three subgroups. An acute PE iNO-group ( n = 6) received iNO at 40 ppm at one, three, six, nine and 12 hours after onset of PE. Vehicle animals ( n = 6) received PE, but no active treatment. A third group of sham animals ( n = 6) received neither PE nor treatment. Animals were evaluated using intravascular pressures, respiratory parameters, biochemistry and intracardiac pressure-volume measurements. Results The administration of PE increased mean pulmonary artery pressure (mPAP) (vehicle vs sham; 33.3 vs 17.7 mmHg, p < 0.0001), pulmonary vascular resistance (vehicle vs sham; 847.5 vs 82.0 dynes, p < 0.0001) and right ventricular arterial elastance (vehicle vs sham; 1.2 vs 0.2 mmHg/ml, p < 0.0001). Significant mPAP reduction by iNO was preserved at 12 hours after the onset of acute PE (vehicle vs iNO; 0.5 vs –3.5 mmHg, p < 0.0001). However, this response was attenuated over time ( p = 0.0313). iNO did not affect the systemic circulation. Conclusions iNO is a safe and effective pulmonary vasodilator both in the immediate and prolonged phase of acute PE in an in-vivo porcine model of intermediate-risk PE.

scholarly journals Cardiomyopathy and pregnancy

Heart ◽  
2019 ◽  
Vol 105 (20) ◽  
pp. 1543-1551 ◽  
Author(s):  
Maria Schaufelberger
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Right Ventricular ◽  
Dilated Cardiomyopathy ◽  
Ventricular Arrhythmias ◽  
Left Ventricular ◽  
Peripartum Cardiomyopathy ◽  
High Risk Patients ◽  
Risk Patients ◽  
In Pregnancy

Cardiomyopathy is a group of disorders in which the heart muscle is structurally and functionally abnormal in the absence of other diseases that could cause observed myocardial abnormality. The most common cardiomyopathies are hypertrophic and dilated cardiomyopathy. Rare types are arrhythmogenic right ventricular, restrictive, Takotsubo and left ventricular non-compaction cardiomyopathies. This review of cardiomyopathies in pregnancy shows that peripartum cardiomyopathy is the most common cardiomyopathy in pregnancy. Peripartum cardiomyopathy develops most frequently in the month before or after partum, whereas dilated cardiomyopathy often is known already or develops in the second trimester. Mortality in peripartum cardiomyopathy varies from <2% to 50%. Few reports on dilated cardiomyopathy and pregnancy exist, with only a limited number of patients. Ventricular arrhythmias, heart failure, stroke and death are found in 39%–60% of high-risk patients. However, patients with modest left ventricular dysfunction and good functional class tolerated pregnancy well. Previous studies on >700 pregnancies in 500 women with hypertrophic cardiomyopathy showed that prognosis was generally good, even though three deaths were reported in high-risk patients. Complications include different types of supraventricular and ventricular arrhythmias, heart failure and ischaemic stroke. Recent studies on 200 pregnancies in 100 women with arrhythmogenic right ventricular cardiomyopathy have reported symptoms, including heart failure in 18%–33% of pregnancies. Ventricular tachycardia was found in 0%–33% of patients and syncope in one patient. Information on rare cardiomyopathies is sparse and only presented in case reports. Close monitoring by multidisciplinary teams in referral centres that counsel patients before conception and follow them throughout gestation is recommended.

Right ventricular adaptation in the critical phase after acute intermediate-risk pulmonary embolism

2020 ◽  
pp. 204887262092525 ◽  
Author(s):  
Mads Dam Lyhne ◽  
Jacob Gammelgaard Schultz ◽  
Anders Kramer ◽  
Christian Schmidt Mortensen ◽  
Jens Erik Nielsen-Kudsk ◽  
...  
Keyword(s):  
Pulmonary Embolism ◽  
Arterial Pressure ◽  
Right Ventricular ◽  
Acute Pulmonary Embolism ◽  
Pulmonary Arterial Pressure ◽  
Intermediate Risk ◽  
Right Ventricular Afterload ◽  
Mean Pulmonary Arterial Pressure ◽  
Ventricular Afterload ◽  
Pulmonary Arterial

Background The haemodynamic response following acute, intermediate-risk pulmonary embolism is not well described. We aimed to describe the cardiovascular changes in the initial, critical phase 0–12 hours after acute pulmonary embolism in an in-vivo porcine model. Methods Pigs were randomly allocated to pulmonary embolism ( n = 6) or sham ( n = 6). Pulmonary embolism was administered as autologous blood clots (20 × 1 cm) until doubling of mean pulmonary arterial pressure or mean pulmonary arterial pressure was greater than 34 mmHg. Sham animals received saline. Cardiopulmonary changes were evaluated for 12 hours after intervention by biventricular pressure–volume loop recordings, invasive pressure measurements, arterial and central venous blood gas analyses. Results Mean pulmonary arterial pressure increased ( P < 0.0001) and stayed elevated for 12 hours in the pulmonary embolism group compared to sham. Pulmonary vascular resistance and right ventricular arterial elastance (right ventricular afterload) were increased in the first 11 and 6 hours, respectively, after pulmonary embolism ( P < 0.01 for both) compared to sham. Right ventricular ejection fraction was reduced ( P < 0.01) for 8 hours, whereas a near-significant reduction in right ventricular stroke volume was observed ( P = 0.06) for 4 hours in the pulmonary embolism group compared to sham. Right ventricular ventriculo–arterial coupling was reduced ( P < 0.05) for 6 hours following acute pulmonary embolism despite increased right ventricular mechanical work in the pulmonary embolism group ( P < 0.01) suggesting right ventricular failure. Conclusions In a porcine model of intermediate-risk pulmonary embolism, the increased right ventricular afterload caused initial right ventricular ventriculo–arterial uncoupling and dysfunction. After approximately 6 hours, the right ventricular afterload returned to pre-pulmonary embolism values and right ventricular function improved despite a sustained high pulmonary arterial pressure. These results suggest an initial critical and vulnerable phase of acute pulmonary embolism before haemodynamic adaptation.

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