ekg at presentation. ekg next day initial ekg f/u ekg

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EKG at presentation

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Page 1: EKG at presentation. EKG next day Initial EKG F/u EKG

EKG at presentation

Page 2: EKG at presentation. EKG next day Initial EKG F/u EKG

EKG next day

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Initial EKG

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F/u EKG

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Massive PE

Matt White

November 3, 2009

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Objectives

• PE Basics

• Massive PE

• Medical treatment

• Lytics

• Embolectomy

• IVC Filters

• Follow-up

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Virchow’s triad

• Thrombosis: triggered by venostasis, hypercoagulability, and vessel wall inflammation.

• All clinical risk factors for DVT/PE have their basis in one or more elements of the triad.

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PE Incidence

• In the United States, incidence is 1 per 1000

• 250,000 new cases annually in US

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Is that enough?

• autopsy studies show that equal number of patients are diagnosed with PE at autopsy vs. diagnosis by clinicians

• Easy diagnosis to miss

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Massive PE

• occlusion of the pulmonary artery that exceeds 50% of its cross-sectional area, resulting in progressive hemodynamic compromise

• Usually defined as presenting with systolic blood pressure < 90 mmHg.

• In two large international studies, this accounted for 4 - 4.5% of all PE patients.

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Clinical course

• obstruction of the PA to this degree initiates a cascade of physiologic events, which if not interrupted early, ultimately results in cardiac arrest and death in up to 70% of patients in the first hour

• Not solely dependent on size of clot, rather on clot and functional capability of the patient's cardiovascular system.

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Medical treatment of massive PE

• Supplemental oxygen • High dose IV heparin• Hemodynamic support

–  IV fluids (empiric 500 mL) • increased right ventricular (RV) wall stress can decrease the

ratio of RV oxygen supply to demand. (ischemia, deterioration of RV function, and worse RV failure)

– Vasopressors (no evidence for which one) •  Norepinephrine, epinephrine, or dopamine usually first line

• Thrombolytics (if no contraindications)

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Thrombolytics

• No clinical trial with conclusive mortality benefit.  – Meta analysis of 8 RCTs (n=679); heparin & lytics vs

heparin, no difference in mortality (OR 0.89 [0.45-1.78]), major hemorrhage (OR 1.61 [0.91-2.86]), or minor hemorrhage (OR 1.98 [0.68-5.75])

• Transient improvement in hemodynamics – Improved RV function (after 12hrs, gone by 7 days)– Lower PA pressures

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ICOPER (International Cooperative Pulmonary Embolism Registry)

• 108 patients with massive PE• Thrombolysis was performed in 33 patients,

surgical embolectomy in 3, and catheter embolectomy in 1

• Thrombolytic therapy did not reduce 90-day mortality (46.3%; [31-64.8%] vs. 55.1% [44.3-66.7%]. Hazard Ratio of 0.79.

• Recurrent PE rates at 90 days similar in patients with and without thrombolytic therapy (12% for both).

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Indications for thrombolytics

• Persistent hypotension due to PE (ie, massive PE) is most widely accepted indication

•  Other considerations – severe hypoxemia – large perfusion defects – right ventricular dysfunction – free-floating right atrial or ventricular embolus – patent foramen ovale

• Thrombolysis should be considered only after PE has been confirmed (in most cases)

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Risks of thrombolytics

• Increased risk of major hemorrhage (19% of patients)– intracranial hemorrhage (5%)– retroperitoneal hemorrhage (15%)– GI bleed (30%)– Unknown site of bleeding (45%)

• Menstruation not a contraindication

• Allergic reactions– More with streptokinase (0.5%, mild reaction in 10%)

•From retrospective analysis of 104 patients

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Administering thrombolytics

• Bolus infusion may be effective more quickly without increase risk of bleeding

• No evidence that intrapulmonary arterial infusion of greater benefit than peripheral venous infusion

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Pearls of thrombolytics

• Avoid unnecessary invasive procedures (especially arterial punctures)

• Discontinue anticoagulant therapy (usually)

• No evidence for superiority between different thrombolytic agents

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Embolectomy

• considered when patient's presentation is severe enough to warrant thrombolysis (e.g., persistent hypotension), but thrombolysis either fails or is contraindicated.

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Catheter embolectomy

• Rheolytic: injecting pressurized saline through the catheter's distal tip, which macerates the emboli – large venous sheath or a venous cut-down is

required to insert the large catheter, which increases the risk of bleeding at the insertion site

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Catheter embolectomy

• Rotational: rotational catheter fragmentation – uses conventional catheters

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Surgical embolectomy

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Surgical embolectomy

• first successful surgical pulmonary embolectomy was performed by Kirschner in 1924

• Initially performed blindly as a closed cardiac procedure

• Now performed on cardiopulmonary bypass with clots extracted from the opened PAs under direct visualization

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Surgical embolectomy Indication

• Main: systemic hypotension due to PE in a patient in whom thrombolysis is contraindicated– Possible: echocardiographic evidence of an

embolus trapped within a patent foramen ovale, the right atrium, or the right ventricle

• Limited to large medical centers because an experienced surgeon and cardiopulmonary bypass are required

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Procedural logistics

• Transesophageal echocardiography (TEE) to look for extrapulmonary thrombi (ie, RA, RV or vena cava).

• In series of 50 patients with PE, TEE detected extrapulmonary thrombi in 13 patients (26%), which altered the surgical management of five patients (10%)

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Mortality of surgical embolectomy

• Estimates of mortality vary widely from 10-60%

• Mortality after cardiac arrest due to PE is extremely high in the nonsurgical setting as well.

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Indicators of Mortality

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IVC Filter Indications

• Absolute contraindication to anticoagulation (e.g., active bleeding)

• Recurrent PE despite adequate anticoagulant therapy

• Complication of anticoagulation (e.g., severe bleeding)

• Hemodynamic or respiratory compromise that is severe enough that another PE may be lethal

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Algorithm (from surgeons)

• Large thrombus in pulmonary artery + hemodynamic instability requiring vasopressor support and evidence of impending right ventricular failure = open embolectomy.

• Mild hemodynamic instability (without evidence of severe RV strain) = thrombolytic therapy ( if no contraindications)– Serial echocardiograms should be performed to evaluate for

improvement. – If thrombolytic therapy is contraindicated and catheter

thrombectomy is readily available, then consideration for this technique is appropriate.

– If patient has large proximal thrombus and is hemodynamically stable but cannot receive thrombolytics or catheter thrombectomy, open embolectomy is then indicated.

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References

• Kucher N, Rossi E, De Rosa M, Goldhaber SZ. Massive pulmonary embolism. Circulation 2006;113:577-582.

• Dauphine C, Omari B. Pulmonary Embolectomy for Acute Massive Pulmonary Embolism. The Annals of Thoracic Surgery. 2005; 79(4) 1240-1244

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