pulmonary embolism and methods of treatment nizhny novgorod state medical academy department of...
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Pulmonary embolismand
methods of treatment
Pulmonary embolismand
methods of treatment
Nizhny Novgorod state medical Academy
Department of Hospital Surgery
Medvedev A.P.Sobolev Y.A.
Annually0,1% of population die
from venous thromboembolic complications in the world
StatisticsStatistics
1. Cohen A.T. et al. 2007 2. Heit J.A. et al. 2005
And 3 million deaths in the world.
Nearly 300,000 deaths in USA.(2)
Pulmonary embolism causes more than 500,000 deaths in Europe (1)
1. Dobesh P.P. Pharmacotherapy, 20092. House of Commons Health Committee Second Report of Session 2004-2005
Every year more than 640 million £ is spent in the UK (2)
In the USA the economic losses from VTEC are $ 1.5 billion $ per year (1)
ExpendituresExpenditures
Acute pulmonary embolism:
the myths and misconceptions.
Acute pulmonary embolism:
the myths and misconceptions. …the massive PE always leads to the death of the patient…
…if the patient has survived, it means that he's had an embolism of peripheral branches of PA…
…patients with pulmonary embolism of peripheral branches of PA do not need any specialized assistance…
Defenition:Defenition:
• Pulmonary thromboembolism – is a sudden
obstruction of the branches of the pulmonary artery
by thromboemboli, initially formed in the veins of the
systemic circulation or in the right heart which is the
greatest threat in the development of pulmonary
hypertension and failure of the right ventricle, which
is observed in occlusion over 50% of the arterial
channel.
Etiology: Etiology: Sources of emboli:• The SVC system – 0,4%• Right heart – 10,4%• The IVC system – 84,5%
Sources of emboli:• The SVC system – 0,4%• Right heart – 10,4%• The IVC system – 84,5%
Localization emboli:• Smaller branches – 27,1%• Equity and segmental– 17,1%• Trunk and main branches– 55,8%
Localization emboli:• Smaller branches – 27,1%• Equity and segmental– 17,1%• Trunk and main branches– 55,8%
* Embolism of segmental and equity branches causes death in only 6.4% of patients.
* Embolism of main PA and major branches causes fulminant death in 61,3% of patients
Mortality riskat acute PE
Risk factors
Clinical (shock or hypotension)
RVdysfunction
Myocardial
damage High risk >15% + +* +*
Intermediate risk 3-15% – + + – + – +
Low risk <1% – – –* is not necessary to confirm RV dysfunction to determination high-risk of death if the shock or hypotension is present.
Mortality risk stratification in acute pulmonary embolism.
Mortality risk stratification in acute pulmonary embolism.
Guidelines on the diagnosis and management of acute pulmonary embolism (2008)
Clinical types of pulmonary embolismClinical types of pulmonary embolism
Acute (12,8%) Acute start, chest pain, breathlessness, hypotension, acute heart failure.
Subacute (31,4%) Progressive lung and heart failure , pneumonia, cough with bloody sputum.
Reccurent (41,8%)Reccurent episodes of breathlessness, syncope, pneumonia.
Aims of diagnostic: Aims of diagnostic:
• To confirm the presence of pulmonary
embolism.
• To identify the localization and lesion
area.
• To estimate the severity of
hemodynamic disorders
• To determine the source of
embolization
Сlinical presentation Сlinical presentation
Pulmonary and pleural syndrome
*Breathlessness
*Cyanosis of the face and the upper
half of the body
*Chest pain
*Cough with bloody sputum
Cardiac syndrome
*Angina
*Tachycardia
*Hypotension
Cerebral syndrome
*Syncope
*Hemiplegia
(V.S. Saveliev, E.G. Yablokov, A.I. Kirienko, 1979)
DIAGNOSTICSDIAGNOSTICS
Echo:Allows us to detect the thromboemboli
in the pulmonary artery and determine the severity of pulmonary hypertension.
ECG: acute RBBB, overload of RA
MSCT: determination of localization of tromboemboli
X-rayExpansion of the roots of the lungs decrease of
pulmonary patternPathological pulmonary shadows
(atelectasis)Pleurisy
High standing of the diaphragm
Cardiac Cath :«Amputation» syndrome of branches of the pulmonary arteryManometry (35-80 mm Hg)Scintigraphy- violation of lung perfusion
Dysfunction of the right ventricle in acute pulmonary embolism
Dysfunction of the right ventricle in acute pulmonary embolism
Overstrain signs of the right ventricle.
Dilatation of the right ventricleEDV >30 mm
Hypokinesis of free wall of the right ventricle
The velocity of tricuspidregurgitation in systole >2,6 м/с
Victor Savelyev – a Russian pioneer
in diagnostics, treatment
and prophylaxis
of pulmonary embolism
*Normalization of hemodynamics
*Restoration ofpulmonary arteries
*Recurrency prevention
Treatment objectives:Treatment objectives:
I. Ohotin
Aims of treatment of PE Aims of treatment of PE 1. Removing threat of death from acute
heart failure
2. Improvement of lung perfusion and prevention of chronic pulmonary hypertension
3. Recurrency prevention
Treatment choiceTreatment choice??1. Pharmacological
embolectomy
(thrombolytic therapy)
2. Open embolectomy
3. Endovascular embolectomy
Types of localization of emboli in PETypes of localization of emboli in PE
5- year Pressure in PA survival
rate < 30 90 %
31 - 40 50 %
41 - 50 35 %
> 50 10 %
ThrombolysisThrombolysis
• Thrombolytic therapy leads to a fast recovery of
the occluded pulmonary artery, reducing
pulmonary hypertension and overstrain of the
right ventricle.
• The indication for therapy with thrombolytics is
the development of acute massive pulmonary
embolism with symptoms of arterial
hypotension, or shock.
• Thrombolytic therapy is associated with
increased risk of bleeding.
Modes of thrombolytic therapyin acute pulmonary embolism
Modes of thrombolytic therapyin acute pulmonary embolism
Streptokinase250 000 IU as a loading dose over 30 minutes, then 100 000 IU/h for 12-24 hoursBoost mode: 1500000 IU for 2 hours.
Urokinase4400 IU/kg as a loading dose over 10 minutes, then 4400 IU/kg/h in 12-24 hoursBoost mode: 3000000 IU for 2 hours.
Alteplaza10 mg intravenous bolus, then 90 mg for 2 hours,or 0.6 mg/kg for 15 minutes (maximum dose of 50 mg)
• Shock phase - acute condition, with severe disturbances of hemodynamics (clinically apparent);
• The period of relative compensation of the right ventricle;
• The acute deterioration in hemodynamics, due to decompensation of the right ventricle.
Surgical treatment in these cases is accompanied by high mortality
«Wait for death to operate???»
TLT with "open eyes" TLT with "open eyes"
We support the accelerated mode of conducting TLT for dynamic control of pressure in the pulmonary artery.
TLT is effective if there is a progressive reduction of pressure in the pulmonary artery.
THROMBOLYTIC THERAPYHELPS:
THROMBOLYTIC THERAPYHELPS:
Lysis of thromboemboli (86%);
To increase the effectiveness of antishock therapy;
To increase the period of relative compensation function of the right heart;
To improve the peripheral blood flow in the pulmonary artery;
To restore the patency of the veins of systemic circulation and recurrency prevention of pulmonary embolism.
Contraindications to thrombolytic therapy
Contraindications to thrombolytic therapy
Absolute contraindications:
Hemorrhagic stroke or stroke of unknown character
Ischemic stroke for the last 6 months
A tumor of the central nervous system
Trauma or surgery (for 3 weeks)
Recent gastrointestinal bleeding (last month)
Bleeding of unknown genesis
Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.
Contraindications to thrombolytic therapy
Contraindications to thrombolytic therapy
Relative contraindications:
Transient ischemic attack for the last 6 months
Taking oral anticoagulants
Pregnancy or the postpartum period for 1 month
Puncture vessels with impossibility compression
Injury in consequence after resuscitation
Refractory hypertension
Systolic blood pressure of more than 180 mm Hg
Infectious endocarditis
Active peptic ulcer
Van de WF et al. Eur. Heart J. 2003. Vol. 24. P. 28-60.
Residual pulmonary hypertension more than 30 mm Hg requires:
Residual pulmonary hypertension more than 30 mm Hg requires:
MSCT or APG
central occlusion is indication to
surgery
(open or endovascular)
in other variants - pharmacotherapy (under the
control of the pulm.pressure)
Basic therapy(cardiac glycosides, diuretics,
anticoagulantsPhlebotonic)
Specific drugs(Sildenofil, Vasaprostan
Ventavis)
Indications for surgery(in inefficiency or inability TLT)
Indications for surgery(in inefficiency or inability TLT)
1. The pressure in the pulmonary artery > 50 mm Hg with a shock, progressive dysfunction of RV and severe arterial hypoxemia;
• 2. The existence of intracardiac tromboemboli;
• 3. Central or "mixed" localization of emboli in the pulmonary arteries.
Patiens Patiens • 81 patients with subtotal obstruction of
the main pulmonary artery or it΄s main branches were operated: 41 male, and 40 female patients;
• Mean age – 39,52 (from 17 to 83) years;
• In all cases, pulmonary embolism (PE) was determined as massive.
The algorithm of surgical treatmentThe algorithm of surgical treatment
Ppulm > 50
Central 2-sided defeat
APG, MSCT
Open embolectomy in the specialized clinic
The algorithm of surgical treatmentThe algorithm of surgical treatment
Ppulm > 50
APG, MSCT
Central and
peripheral
defeat
Open embolectomy with retrograde
perfusion
ResultsResults
Positive echocardiography dynamics to the third day of the postoperative period
before the operation after the operation
Finding the source of embolization
Finding the source of embolization
ultrasound duplex scanning
It is impossible to
predict which of
patients will develop
recurrence of PE.
You can prevent thrombotic complications
by using adequate preventive measures.
The duration of prophylaxis of thrombosis
The duration of prophylaxis of thrombosis
Diagnosis The duration of anticoagulant prophylaxis
Trauma, surgery 3 months (shin) 6 months (hip)
Idiopathic thrombosis 6 months
Relapsing course of diseaseHereditary thrombophilia, implantation cava-filter
Lifelong therapy
Oncology To eliminate the causes of the disease
ConclusionsConclusions
• TLT increases the efficiency of
antishock therapy, prolongs the period
of relative compensation function of
the right heart, improves peripheral
blood in the pulmonary arteries and
prevents recurrence of pulmonary
embolism
ConclusionsConclusions
• In 50% of cases TLT is a radical method of treatment of pulmonary embolism. And only when it is not efficient or when there are contraindications an open embolectomy is needed to be performed.
ConclusionsConclusions
• Surgical treatment is an effective method
of correction of PE and its complications.
Which leads to a complete regression of
cardio-pulmonary pathology.
Thank you
for attention !
Thank you
for attention !