1
|
Monteleone P, Patel A, Paul J. Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism. Curr Cardiol Rep 2024:10.1007/s11886-024-02060-3. [PMID: 38656585 DOI: 10.1007/s11886-024-02060-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies. RECENT FINDINGS Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.
Collapse
Affiliation(s)
- Peter Monteleone
- Department of Medicine, University of Texas at Austin Dell School of Medicine, Austin, USA.
- Ascension Texas Cardiovascular, Austin, TX, USA.
| | - Akash Patel
- Department of Medicine, University of Texas at Austin Dell School of Medicine, Austin, USA
| | | |
Collapse
|
2
|
Kadri AN, Alrawashdeh R, Soufi MK, Elder AJ, Elder Z, Mohamad T, Gnall E, Elder M. Mechanical Support in High-Risk Pulmonary Embolism: Review Article. J Clin Med 2024; 13:2468. [PMID: 38730997 PMCID: PMC11084514 DOI: 10.3390/jcm13092468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/13/2024] [Accepted: 04/15/2024] [Indexed: 05/13/2024] Open
Abstract
Acute pulmonary embolism (PE) may manifest with mild nonspecific symptoms or progress to a more severe hemodynamic collapse and sudden cardiac arrest. A substantial thrombotic burden can precipitate sudden right ventricular strain and failure. Traditionally, systemic thrombolytics have been employed in such scenarios; however, patients often present with contraindications, or these interventions may prove ineffective. Outcomes for this medically complex patient population are unfavorable, necessitating a compelling argument for advanced therapeutic modalities or alternative approaches. Moreover, patients frequently experience complications beyond hemodynamic instability, such as profound hypoxia and multiorgan failure, necessitating assertive early interventions to avert catastrophic consequences. The existing data on the utilization of mechanical circulatory support (MCS) devices are not exhaustive. Various options for percutaneous MCS devices exist, each possessing distinct advantages and disadvantages. There is an imminent imperative to develop a tailored approach for this high-risk patient cohort to enhance their overall outcomes.
Collapse
Affiliation(s)
- Amer N. Kadri
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Razan Alrawashdeh
- Department of Medicine, Faculty of Medicine, University of Jordan, Amman 11942, Jordan
| | - Mohamad K. Soufi
- Division of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX 77550, USA
| | - Adam J. Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
| | - Zachary Elder
- School of Medicine, American University of Caribbean, 33027 Cupecoy, Sint Maarten
| | - Tamam Mohamad
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
| | - Eric Gnall
- Divion of Cardiovascular Medicine, Main Line Health, Lankenau Medical Center, Wynnewood, PA 19096, USA
| | - Mahir Elder
- School of Medicine, Wayne State University, Detroit, MI 48202, USA
- Heart and Vascular Institute, Detroit, MI 48201, USA
- College of Osteopathic Medicine, Michigan State University, East Lansing, MI 48864, USA
- Corewell Health East, Dearborn Hospital, Dearborn, MI 48124, USA
| |
Collapse
|
3
|
Fulton B, Bashir R, Weinberg MD, Lakhter V, Rali P, Pugliese S, Giri J, Kobayashi T. Advanced Treatment of Hemodynamically Unstable Acute Pulmonary Embolism and Clinical Follow-up. Semin Thromb Hemost 2023; 49:785-796. [PMID: 37696292 DOI: 10.1055/s-0043-1772840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
High-risk acute pulmonary embolism (PE), defined as acute PE associated with hemodynamic instability, remains a significant contributor to cardiovascular morbidity and mortality in the United States and worldwide. Historically, anticoagulant therapy in addition to systemic thrombolysis has been the mainstays of medical therapy for the majority of patients with high-risk PE. In efforts to reduce the morbidity and mortality, a wide array of interventional and surgical therapies has been developed and employed in the management of these patients. However, the most recent guidelines for the management of PE have reserved the use of these advanced therapies in scenarios where thrombolytic therapy plus anticoagulation are unsuccessful. This is due largely to the lack of prospective, randomized studies in this population. Stemming from this, the approach to treatment of these patients varies widely depending on institutional experience and resources. Furthermore, morbidity and mortality remain unacceptably high in this population, with estimated 30-day mortality of at least 30%. As such, development of a standardized approach to treatment of these patients is paramount to improving outcomes. Early and accurate risk stratification in conjunction with a multidisciplinary team approach in the form of a PE response team is crucial. With the advent of novel therapies for the treatment of acute PE, in addition to the growing availability of and familiarity with mechanical circulatory support systems, such a standardized approach may now be within reach.
Collapse
Affiliation(s)
- Brian Fulton
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, New York
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Parth Rali
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
| | - Steve Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jay Giri
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| | - Taisei Kobayashi
- Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Cardiovascular Outcomes, Quality and Evaluative Research Center, Philadelphia, Pennsylvania
| |
Collapse
|
4
|
Zala H, Arman HE, Chatterjee S, Kalra A. Unmet Needs and Future Direction for Pulmonary Embolism Interventions. Interv Cardiol Clin 2023; 12:399-415. [PMID: 37290843 DOI: 10.1016/j.iccl.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Venous thromboembolism (VTE) usually develops in the deep veins of the extremities. Pulmonary embolism (PE) is a type of VTE that is most commonly (∼90%) caused by a thrombus that originates from the deep veins of the lower extremities. PE is the third most common cause of death after myocardial infarction and stroke. In this review, the authors investigate and discuss the risk stratification and definitions of the aforementioned categories of PE and further explore the management of acute PE along with the types of catheter-based treatment options and their efficacy.
Collapse
Affiliation(s)
- Harshvardhan Zala
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN 46202-3082, USA
| | - Huseyin Emre Arman
- Department of Medicine, Indiana University School of Medicine, IN 46202-3082, USA
| | - Saurav Chatterjee
- Department of Cardiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY 11549-1000, USA; Interventional Services, New York Community Hospital, Brooklyn, NY 11229, USA
| | - Ankur Kalra
- Franciscan Health, Lafayette, Lafayette, 3900 Street Francis Way, Ste 200, Lafayette, IN 47905, USA.
| |
Collapse
|
5
|
Carroll BJ, Larnard EA, Pinto DS, Giri J, Secemsky EA. Percutaneous Management of High-Risk Pulmonary Embolism. Circ Cardiovasc Interv 2023; 16:e012166. [PMID: 36744463 DOI: 10.1161/circinterventions.122.012166] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.
Collapse
Affiliation(s)
- Brett J Carroll
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Emily A Larnard
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Duane S Pinto
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jay Giri
- Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine (B.J.C., E.A.L., D.S.P., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Smith Center for Outcomes Research in Cardiology (B.J.C., J.G., E.A.S.), Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.,Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia (E.A.S.)
| |
Collapse
|
6
|
Hockstein MA, Singam NS, Papolos AI, Kenigsberg BB. The Role of Echocardiography in Extracorporeal Membrane Oxygenation. Curr Cardiol Rep 2023; 25:9-16. [PMID: 36571660 DOI: 10.1007/s11886-022-01827-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal membrane oxygenation (ECMO) is increasingly used to temporarily support patients in severe circulatory and/or respiratory failure. Echocardiography is a core component of successful ECMO deployment. Herein, we review the role of echocardiography at different phases on extracorporeal support including candidate identification, cannulation, maintenance, complication vigilance, and decannulation. RECENT FINDINGS During cannulation, ultrasound is used to confirm intended vascular access and appropriate inflow cannula positioning. While on ECMO, echocardiographic evaluation of ventricular loading conditions and hemodynamics, cannula positioning, and surveillance for intracardiac or aortic thrombi is needed for complication mitigation. Echocardiography is crucial during all phases of ECMO use. Specific echocardiographic queries depend on the ECMO type, V-V, or V-A, and the specific cannula configuration strategy employed.
Collapse
Affiliation(s)
- Maxwell A Hockstein
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Narayana Sarma Singam
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Alexander I Papolos
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA.,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA
| | - Benjamin B Kenigsberg
- Department of Critical Care, MedStar Washington Hospital Center, Washington, DC, USA. .,Division of Cardiology, MedStar Heart and Vascular Institute, MedStar Washington Hospital Center, 110 Irving St., NW, Room A121, Washington, DC, 20010, USA.
| |
Collapse
|
7
|
Jamil A, Johnston-Cox H, Pugliese S, Nathan AS, Fiorilli P, Khandhar S, Weinberg MD, Giri J, Kobayashi T. Current interventional therapies in acute pulmonary embolism. Prog Cardiovasc Dis 2021; 69:54-61. [PMID: 34822807 DOI: 10.1016/j.pcad.2021.11.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 11/14/2021] [Indexed: 11/26/2022]
Abstract
Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. The management of PE is currently evolving given the development of new technologies and team-based approaches. This document will focus on risk stratification of PEs, review of the current interventional therapies, the role of clinical endpoints to assess the effectiveness of different interventional therapies, and the role for mechanical circulatory support in the complex management of this disease.
Collapse
Affiliation(s)
- Alisha Jamil
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Hillary Johnston-Cox
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Steven Pugliese
- Division of Pulmonary and Critical Care Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America
| | - Ashwin S Nathan
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Paul Fiorilli
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Sameer Khandhar
- Division of Cardiovascular Medicine, Penn Presbyterian Medical Center, Philadelphia, PA 19104, United States of America
| | - Mitchell D Weinberg
- Zucker School of Medicine at Hofstra/Northwell, Staten Island University Hospital, Staten Island, NY 10305, United States of America
| | - Jay Giri
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America
| | - Taisei Kobayashi
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, United States of America; Center for Cardiovascular Outcomes, Quality, and Evaluative Research, United States of America.
| |
Collapse
|
8
|
Catheter-based therapies in acute and chronic pulmonary embolism. Curr Opin Cardiol 2021; 36:704-710. [PMID: 34508032 DOI: 10.1097/hco.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of this study is to summarize currently available catheter-based therapies in acute and chronic pulmonary embolic disease. RECENT FINDINGS Catheter-based therapies to treat acute pulmonary embolism and its sequelae such as chronic thromboembolic pulmonary hypertension (CTEPH) are emerging as the next frontier within interventional cardiology. However, the true benefit of these catheter-based therapies in intermediate-risk and high-risk pulmonary embolism and CTEPH remains unclear. The current evidence supporting such interventions comes primarily from small single-arm studies in acute pulmonary embolism and case series in CTEPH. SUMMARY Appropriately powered randomized controlled trials with meaningful clinical outcomes as endpoints are needed to elucidate the true benefit of catheter-based therapies in pulmonary embolism compared with other treatment modalities such as anticoagulation and systemic thrombolysis in acute pulmonary embolism and riociguat and pulmonary endarterectomy in CTEPH.
Collapse
|
9
|
Goldberg JB, Spevack DM, Ahsan S, Rochlani Y, Ohira S, Spencer P, Kai M, Malekan R, Spielvogel D, Lansman S. Comparison of Surgical Embolectomy and Veno-arterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism. Semin Thorac Cardiovasc Surg 2021; 34:934-942. [PMID: 34157383 DOI: 10.1053/j.semtcvs.2021.06.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 06/11/2021] [Indexed: 11/11/2022]
Abstract
Massive pulmonary embolism (MPE) is associated with a 20-50% mortality rate with guideline directed therapy. MPE treatment with surgical embolectomy (SE) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) have shown promising results. In the context of a surgical management strategy for MPE, a comparison of outcomes associated with VA-ECMO or SE was performed. A retrospective review of a single institution cardiac surgery database was performed, identifying MPE treated with SE or VA-ECMO between 2005-2020. Primary outcome was in-hospital survival. 59 MPE [27 (46.8%) VA-ECMO vs 32 (54.2%) SE] were identified. All presented with elevated cardiac biomarkers, tachycardia (mean heart rate 113 ± 20 beats/minute), hypotension (mean systolic blood pressure 85 ± 22 mm Hg) and vasopressors requirement, without significant differences between cohorts. Preoperative CPR was performed in 37.3% (22/59), without a significant difference between cohorts. More VA-ECMO presented with questionable neurologic status (GCS ≤ 4) [9/27 (33.3%) vs 2/32 (6.2%), P = 0.008] and more VA-ECMO failed thrombolysis [8/27 (29.6) vs 2/32 (6.3), P = 0.014]. All presented with severe RV dysfunction, by discharge all had normalization of echocardiographic RV function. Overall mortality was 10.2%, with a trend toward higher mortality among VA-ECMO [14.9% (4/27) vs 6.3% (2/32) P = 0.14]. CPR was independently associated with death (OR 10.8, P = 0.02) whereas treatment modality was not (OR 0.24). In an extremely unstable MPE population VA-ECMO and SE were safely performed with low mortality while achieving RV recovery. Adverse outcomes were more closely associated with preoperative CPR than with treatment modality.
Collapse
Affiliation(s)
- Joshua B Goldberg
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York.
| | - Daniel M Spevack
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Syed Ahsan
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Yogita Rochlani
- Department of Cardiology, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Suguru Ohira
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Philip Spencer
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Masashi Kai
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ramin Malekan
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - David Spielvogel
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Steven Lansman
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, New York
| |
Collapse
|
10
|
Moore K, Kunin J, Alnijoumi M, Nagpal P, Bhat AP. Current Endovascular Treatment Options in Acute Pulmonary Embolism. J Clin Imaging Sci 2021; 11:5. [PMID: 33598362 PMCID: PMC7881502 DOI: 10.25259/jcis_229_2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/09/2021] [Indexed: 01/08/2023] Open
Abstract
Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.
Collapse
Affiliation(s)
- Kelli Moore
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Jeff Kunin
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Mohammed Alnijoumi
- Department of Medicine, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| | - Prashant Nagpal
- Department of Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Ambarish P Bhat
- Department of Radiology, Section of Pulmonary and Critical Care, University of Missouri, Columbia, Missouri, United States
| |
Collapse
|
11
|
Sertic F, Diagne D, Chavez L, Richards T, Berg A, Acker M, Giri JS, Szeto WY, Khandhar S, Gutsche J, Pugliese S, Fiorilli P, Rame E, Bermudez C. Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism. Eur J Cardiothorac Surg 2020; 58:923-931. [PMID: 32725134 DOI: 10.1093/ejcts/ezaa189] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/28/2020] [Accepted: 05/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.
Collapse
Affiliation(s)
- Federico Sertic
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dieynaba Diagne
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lexy Chavez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Thomas Richards
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ashley Berg
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Acker
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jay S Giri
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sameer Khandhar
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jacob Gutsche
- Department of Intensive Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Pugliese
- Department of Medicine, Division of Pulmonology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paul Fiorilli
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eduardo Rame
- Department of Medicine, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Christian Bermudez
- Department of Surgery, Division of Cardiovascular Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
12
|
Abstract
Purpose of the Review Over 100,000 cardiovascular-related deaths annually are caused by acute pulmonary embolism (PE). While anticoagulation has historically been the foundation for treatment of PE, this review highlights the recent rapid expansion in the interventional strategies for this condition. Recent Findings At the time of diagnosis, appropriate risk stratification helps to accurately identify patients who may be candidates for advanced therapeutic interventions. While systemic thrombolytics (ST) is the mostly commonly utilized intervention for high-risk PE, the risk profile of ST for intermediate-risk PE limits its use. Assessment of an individualized patient risk profile, often via a multidisciplinary pulmonary response team (PERT) model, there are various interventional strategies to consider for PE management. Novel therapeutic options include catheter-directed thrombolysis, catheter-based embolectomy, or mechanical circulatory support for certain high-risk PE patients. Current data has established safety and efficacy for catheter-based treatment of PE based on surrogate outcome measures. However, there is limited long-term data or prospective comparisons between treatment modalities and ST. While PE diagnosis has improved with modern cross-sectional imaging, there is interest in improved diagnostic models for PE that incorporate artificial intelligence and machine learning techniques. Summary In patients with acute pulmonary embolism, after appropriate risk stratification, some intermediate and high-risk patients should be considered for interventional-based treatment for PE.
Collapse
|
13
|
Pozzi M, Metge A, Martelin A, Giroudon C, Lanier Demma J, Koffel C, Fornier W, Chiari P, Fellahi JL, Obadia JF, Armoiry X. Efficacy and safety of extracorporeal membrane oxygenation for high-risk pulmonary embolism: A systematic review and meta-analysis. Vasc Med 2020; 25:460-467. [PMID: 32790536 DOI: 10.1177/1358863x20944469] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
High-risk pulmonary embolism (PE) requires hemodynamic and respiratory support along with reperfusion strategies. Recently updated European guidelines assign a low class of recommendation to extracorporeal membrane oxygenation (ECMO) for high-risk PE. This systematic review assessed clinical outcomes after ECMO in high-risk PE. We searched electronic databases including PubMed, Embase and Web of Science from January 2000 to April 2020. Efficacy outcomes included in-hospital survival with good neurological outcome and survival at follow-up. Safety outcomes included lower limb ischemia and hemorrhagic and ischemic stroke. Where possible (absence of high heterogeneity), meta-analyses of outcomes were undertaken using a random-effects model. We included 16 uncontrolled case-series (533 participants). In-hospital survival with good neurological outcome ranged between 50% and 95% while overall survival at follow-up ranged from 35% to 95%, both with a major degree of heterogeneity (I2 > 70%). The prevalence of lower limb ischemia was 8% (95% CI 3% to 15%). The prevalence of stroke (either hemorrhagic or ischemic) was 11% (95% CI 3% to 23%), with notable heterogeneity (I² = 63.35%). Based on currently available literature, it is not possible to draw definite conclusions on the usefulness of ECMO for high-risk PE. Prospective, multicenter, large-scale studies or nationwide registries are needed to best define the role of ECMO for high-risk PE. PROSPERO registration ID: CRD42019136282.
Collapse
Affiliation(s)
- Matteo Pozzi
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Augustin Metge
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Anthony Martelin
- Medical Devices Unit - Pharmacy Department, "Edouard Herriot" Hospital, - Lyon University Hospitals, Lyon, France
| | - Caroline Giroudon
- Central Documentation Department, Hospices Civils de Lyon, Lyon, France
| | - Justine Lanier Demma
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Catherine Koffel
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - William Fornier
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Pascal Chiari
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Luc Fellahi
- Department of Anesthesia and ICU, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Jean Francois Obadia
- Department of Cardiac Surgery, "Louis Pradel" Cardiologic Hospital, Lyon, France
| | - Xavier Armoiry
- University of Lyon, School of Pharmacy - Pharmacy Department (ISPB)/UMR CNRS 5510 MATEIS/"Edouard Herriot" Hospital - Lyon University Hospitals, Lyon, France
| |
Collapse
|
14
|
Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, Nigoghossian CD, Ageno W, Madjid M, Guo Y, Tang LV, Hu Y, Giri J, Cushman M, Quéré I, Dimakakos EP, Gibson CM, Lippi G, Favaloro EJ, Fareed J, Caprini JA, Tafur AJ, Burton JR, Francese DP, Wang EY, Falanga A, McLintock C, Hunt BJ, Spyropoulos AC, Barnes GD, Eikelboom JW, Weinberg I, Schulman S, Carrier M, Piazza G, Beckman JA, Steg PG, Stone GW, Rosenkranz S, Goldhaber SZ, Parikh SA, Monreal M, Krumholz HM, Konstantinides SV, Weitz JI, Lip GYH. COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review. J Am Coll Cardiol 2020; 75:2950-2973. [PMID: 32311448 PMCID: PMC7164881 DOI: 10.1016/j.jacc.2020.04.031] [Citation(s) in RCA: 2089] [Impact Index Per Article: 522.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 04/15/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease-2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, because of excessive inflammation, platelet activation, endothelial dysfunction, and stasis. In addition, many patients receiving antithrombotic therapy for thrombotic disease may develop COVID-19, which can have implications for choice, dosing, and laboratory monitoring of antithrombotic therapy. Moreover, during a time with much focus on COVID-19, it is critical to consider how to optimize the available technology to care for patients without COVID-19 who have thrombotic disease. Herein, the authors review the current understanding of the pathogenesis, epidemiology, management, and outcomes of patients with COVID-19 who develop venous or arterial thrombosis, of those with pre-existing thrombotic disease who develop COVID-19, or those who need prevention or care for their thrombotic disease during the COVID-19 pandemic.
Collapse
Affiliation(s)
- Behnood Bikdeli
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
| | - Mahesh V Madhavan
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York.
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (Instituto de Ramón y Cajal de Investigación Sanitaria), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Taylor Chuich
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Isaac Dreyfus
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Elissa Driggin
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Mohammad Madjid
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, Texas
| | - Yutao Guo
- Department of Cardiology, Chinese PLA General Hospital, Beijing, China
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Hu
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jay Giri
- Cardiovascular Division, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, Vermont
| | - Isabelle Quéré
- Department of Vascular Medicine, University of Montpellier, Centre Hospitalier Universitaire Montpellier, InnoVTE F-CRIN Network, Montpellier, France
| | - Evangelos P Dimakakos
- Oncology Unit GPP, Sotiria General Hospital Athens School of Medicine, Athens, Greece
| | - C Michael Gibson
- Harvard Medical School, Boston, Massachusetts; Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Giuseppe Lippi
- Laboratory of Clinical Chemistry and Hematology, University Hospital of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Haematology Laboratory, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia; Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia
| | - Jawed Fareed
- Loyola University Medical Center, Chicago, Illinois
| | - Joseph A Caprini
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois
| | - Alfonso J Tafur
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois; Division of Vascular Medicine, Department of Medicine, NorthShore University HealthSystem, Skokie, Illinois
| | - John R Burton
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Dominic P Francese
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Elizabeth Y Wang
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, Hospital Papa Giovanni XXIII, University of Milan Bicocca, Bergamo, Italy
| | | | | | - Alex C Spyropoulos
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hofstra University, Hempstead, New York
| | - Geoffrey D Barnes
- Center for Bioethics and Social Science in Medicine, University of Michigan, Ann Arbor, Michigan; Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Ido Weinberg
- Harvard Medical School, Boston, Massachusetts; Massachusetts General Hospital, Boston, Massachusetts
| | - Sam Schulman
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia; McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Marc Carrier
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Gregory Piazza
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | | | - P Gabriel Steg
- INSERM U1148, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, FACT (French Alliance for Cardiovascular Trials), Paris, France; Université Paris, Paris, France; Royal Brompton Hospital, Imperial College London, London, United Kingdom
| | - Gregg W Stone
- Clinical Trials Center, Cardiovascular Research Foundation, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Stephan Rosenkranz
- Cologne Cardiovascular Research Center, Heart Center, Department of Cardiology, University of Cologne, Cologne, Germany
| | - Samuel Z Goldhaber
- Harvard Medical School, Boston, Massachusetts; Brigham and Women's Hospital, Boston, Massachusetts
| | - Sahil A Parikh
- NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, New York; Clinical Trials Center, Cardiovascular Research Foundation, New York, New York
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation (CORE), Yale School of Medicine, New Haven, Connecticut; Department of Health Policy and Administration, Yale School of Public Health, New Haven, Connecticut; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Jeffrey I Weitz
- McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom; Aalborg University, Aalborg, Denmark
| |
Collapse
|
15
|
Tan CW, Balla S, Ghanta RK, Sharma AM, Chatterjee S. Contemporary Management of Acute Pulmonary Embolism. Semin Thorac Cardiovasc Surg 2020; 32:396-403. [PMID: 32353408 DOI: 10.1053/j.semtcvs.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/13/2020] [Indexed: 11/11/2022]
Abstract
Multiple treatment options beyond anticoagulation exist for massive and submassive pulmonary embolism to reduce mortality. For some patients, systemic thrombolytics and catheter-directed thrombolysis are appropriate interventions. For others, surgical pulmonary embolectomy can be life-saving. Extracorporeal life support and right ventricular assist devices can provide hemodynamic support in challenging cases. We propose a management algorithm for the treatment of massive and submassive pulmonary embolism, in conjunction with a multidisciplinary pulmonary embolism response team, to guide clinicians in individualizing treatment for patients in a timely manner.
Collapse
Affiliation(s)
- Corinne W Tan
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Sujana Balla
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Ravi K Ghanta
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Aditya M Sharma
- Department of Medicine, University of Virginia, Health Sciences Center, Charlottesville, Virginia
| | - Subhasis Chatterjee
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas.
| |
Collapse
|
16
|
Zhang R, Kobayashi T, Pugliese S, Khandhar S, Giri J. Interventional Therapies in Acute Pulmonary Embolism. Interv Cardiol Clin 2020; 9:229-241. [PMID: 32147123 DOI: 10.1016/j.iccl.2019.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Treatment of acute pulmonary embolism (PE) historically included anticoagulation and systemic thrombolytic therapy. More recently, catheter guided interventions provided promise of mitigating bleeding risks usually associated with systemic thrombolysis in intermediate to high risk PE patients. Catheter based interventions can broadly be divided into catheter directed thrombolysis and catheter based embolectomy. Both modalities are currently undergoing active research and each has their respective risks and benefits. The decision to administer these advanced therapies for acute PE can be challenging but can be accomplished via a multi-disciplinary PE response team.
Collapse
Affiliation(s)
- Robert Zhang
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Taisei Kobayashi
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Steven Pugliese
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Sameer Khandhar
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA
| | - Jay Giri
- Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, Philadelphia, PA 19104, USA.
| |
Collapse
|
17
|
Rivera-Lebron B, McDaniel M, Ahrar K, Alrifai A, Dudzinski DM, Fanola C, Blais D, Janicke D, Melamed R, Mohrien K, Rozycki E, Ross CB, Klein AJ, Rali P, Teman NR, Yarboro L, Ichinose E, Sharma AM, Bartos JA, Elder M, Keeling B, Palevsky H, Naydenov S, Sen P, Amoroso N, Rodriguez-Lopez JM, Davis GA, Rosovsky R, Rosenfield K, Kabrhel C, Horowitz J, Giri JS, Tapson V, Channick R. Diagnosis, Treatment and Follow Up of Acute Pulmonary Embolism: Consensus Practice from the PERT Consortium. Clin Appl Thromb Hemost 2019; 25:1076029619853037. [PMID: 31185730 PMCID: PMC6714903 DOI: 10.1177/1076029619853037] [Citation(s) in RCA: 129] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Pulmonary embolism (PE) is a life-threatening condition and a leading cause of morbidity and mortality. There have been many advances in the field of PE in the last few years, requiring a careful assessment of their impact on patient care. However, variations in recommendations by different clinical guidelines, as well as lack of robust clinical trials, make clinical decisions challenging. The Pulmonary Embolism Response Team Consortium is an international association created to advance the diagnosis, treatment, and outcomes of patients with PE. In this consensus practice document, we provide a comprehensive review of the diagnosis, treatment, and follow-up of acute PE, including both clinical data and consensus opinion to provide guidance for clinicians caring for these patients.
Collapse
Affiliation(s)
| | | | - Kamran Ahrar
- 3 The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abdulah Alrifai
- 4 University of Miami of Palm Beach Regional Campus/JFK Hospital, Atlantis, FL, USA
| | - David M Dudzinski
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Danielle Blais
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | - Roman Melamed
- 9 Abbott Northwestern Hospital, Minneapolis, MN, USA
| | | | - Elizabeth Rozycki
- 7 The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | | | | | - Parth Rali
- 10 Temple University, Philadelphia, PA, USA
| | | | | | | | | | | | - Mahir Elder
- 14 Wayne State University, Detroit, MI, USA.,15 Michigan State University, East Lansing, MI, USA
| | | | | | | | | | | | | | | | - Rachel Rosovsky
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth Rosenfield
- 5 Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | - Jay S Giri
- 16 University of Pennsylvania, Philadelphia, PA, USA
| | - Victor Tapson
- 21 Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | | |
Collapse
|
18
|
Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, Piazza G, Gladwin MT, Chatterjee S, Kobayashi T, Kabrhel C, Barnes GD. Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association. Circulation 2019; 140:e774-e801. [PMID: 31585051 DOI: 10.1161/cir.0000000000000707] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.
Collapse
|
19
|
Elbadawi A, Mentias A, Elgendy IY, Mohamed AH, Syed MH, Ogunbayo GO, Olorunfemi O, Gosev I, Prasad S, Cameron SJ. National trends and outcomes for extra-corporeal membrane oxygenation use in high-risk pulmonary embolism. Vasc Med 2019; 24:230-233. [PMID: 30834824 DOI: 10.1177/1358863x18824650] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Little is known about the temporal trends and outcomes for extra-corporeal membrane oxygenation (ECMO) in patients with high-risk pulmonary embolism (PE) in the United States. We queried the National Inpatient Sample (NIS) database from 2005 to 2013 to identify patients admitted with high-risk PE. Our objective was to determine trends for ECMO use in patients with high-risk PE. We also assessed in-hospital outcomes among patients with high-risk PE receiving ECMO. We evaluated 77,809 hospitalizations for high-risk PE. There was an upward trend in the utilization of ECMO from 0.07% in 2005 to 1.1% in 2013 ( p = 0.015). ECMO was utilized more in urban teaching hospitals and large hospitals. ECMO use was associated with lower mortality in patients with massive PE ( p < 0.001). In-hospital mortality for patients receiving ECMO was 61.6%, with no change over the observational period ( p = 0.68). Our investigation revealed several independent predictors of increased mortality in patients with high-risk PE using ECMO as hemodynamic support, including: age, female sex, obesity, congestive heart failure, and chronic pulmonary disease. ECMO, therefore, as a rescue strategy or bridge to definitive treatment, may be effective in the management of high-risk PE when selecting patients with favorable clinical characteristics.
Collapse
Affiliation(s)
- Ayman Elbadawi
- 1 Department of Cardiovascular Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Amgad Mentias
- 2 Division of Cardiovascular Medicine, University of Iowa, Iowa City, IA, USA
| | - Islam Y Elgendy
- 3 Division of Cardiovascular Medicine, University of Florida, Gainesville, FL, USA
| | - Ahmed H Mohamed
- 4 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Mohammed Hz Syed
- 4 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Gbolahan O Ogunbayo
- 5 Department of Cardiovascular Medicine, University of Kentucky, Lexington, KY, USA
| | - Odunayo Olorunfemi
- 4 Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Igor Gosev
- 6 Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Sunil Prasad
- 6 Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Scott J Cameron
- 6 Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, NY, USA.,7 Division of Cardiology, University of Rochester Medical Center, Rochester, NY, USA
| |
Collapse
|
20
|
Das Gupta J, Saavedra R, Guliani S, Marinaro J, Rana MA. Decompressive laparotomy for a patient on VA-ECMO for massive pulmonary embolism that suffered traumatic liver laceration after mechanical CPR. J Surg Case Rep 2018; 2018:rjy292. [PMID: 30397436 PMCID: PMC6207845 DOI: 10.1093/jscr/rjy292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 09/22/2018] [Accepted: 10/09/2018] [Indexed: 11/21/2022] Open
Abstract
Massive pulmonary embolism (PE) is an embolus sufficiently obstructing pulmonary blood flow to cause right ventricular (RV) failure and hemodynamic instability. We have utilized veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for early and aggressive intervention for massive PE patients. We present a case of a 61-year-old female placed on VA-ECMO for a massive PE while presenting in cardiac arrest and receiving mechanical cardiopulmonary resuscitation (CPR) via the LUCAS 2.0 device (Physio-Control Inc., Lund, Sweden). The patient suffered a severe liver laceration secondary to mechanical CPR and required a decompressive laparotomy. This case highlights that mechanical CPR during other interventions can lead to malposition of the device and could result in solid organ injury.
Collapse
Affiliation(s)
- Jaideep Das Gupta
- Department of Surgery, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
| | - Ramses Saavedra
- Department of Surgery, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
| | - Sundeep Guliani
- Department of Surgery, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA.,Division of Vascular, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
| | - John Marinaro
- Department of Critical Care, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
| | - Muhammad Ali Rana
- Department of Surgery, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA.,Division of Vascular, University of New Mexico School of Medicine, 2211 Lomas Blvd NE, Albuquerque, NM, USA
| |
Collapse
|