stop that clot
TRANSCRIPT
What Makes a “Massive” PE So Massive?
http://www.hindawi.com/journals/crim/2010/862028/fig1/
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• Patients with PE & subsequent RV dysfunction can be roughly divided in 2 categories– high-risk individuals w/ ‘massive’ PE with SBP</=90 or
pressure drop of >40 mmHg x 15 min– and lower-risk patients with ‘submassive’ PE, whose BP is
preserved but whose RV function is impaired
• Massive PE is <5% of all PEs, but high mortality– Management Strategies and Prognosis of Pulmonary
Embolism Trial-3 (MAPPET-3): • PE-related mortality in those with cardiac arrest: 60%• PE-related mortality in those with cardiogenic shock: 23%• PE-related mortality in those with arterial hypotension: 14%
Risk Stratification
• Studied in hemodynamically stable patients• Meta-analysis: elevated BNP & pro-BNP had
increased risk of adverse in-hospital outcome • Meta-analysis: PE and elevated troponin had
increase in:– short-term risk of death by factor of 5.2 &– increase in risk of death from PE by factor of 9.4
Klok et al. Am J Respir Crit Care Med 2008;178:425-30Becattini et al. Circulation. 2007; 116: 427-433
Making The Diagnosis: CT• Multidetector CT: used
to diagnose or r/o PE• Can also show RV size,
which can be used for prognosis
• In one restrospective study, value <1.0 of RV/LV diameter had 100% negative predictive value for uneventful outcome
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Van der Meer Radiology. 2005 Jun;235(3):798-803
Making The Diagnosis: TTE
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• Typical findings: RV hypokinesis, RV dilatation, intraventricular septal flattening w/ paradoxical motion toward LV, TR, pulmonary HTN, loss of inspiratory collapse of IVC
Making The Diagnosis: TTE
• McConnell’s sign: distinct regional pattern of right ventricular dysfunction, with akinesia of the mid free wall but normal motion at the apex– 94% specificity for acute PE
• RV hypokinesis & dilatation found to be independent predictors of 30-day mortality (in hemodynamically stable)
• Ventricular septal bowing predictor of death related to PE
McConnell et al. Am J Cardiol. 1996 Aug 15;78(4):469-73Kucher et al. Arch Intern Med 2005;165:1777-81.Sanchez et al. Eur Heart J 2008:29:1569-77.Araoz et al. Radiology 2007;242:889-97.
Initial Supportive Treatment
• Provide oxygen & pain control
• Be judicious with IVF since volume overload can worsen RV failure; maintain CVP 15–20 cm H2O
• May need pressors: consider dopamine, Levophed or epinephrine for inotropic and vasopressor effects
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QuickTime™ and a decompressor
are needed to see this picture.
Treatment: Medicine
Wan et al. Circulation 2004;110, 744-749.Kucher et al. Circulation 2006;113, 577-582.
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• Heparin and/or systemic thrombolysis?• 1st RCT: streptokinase+heparin vs heparin alone
(n=8); survival greater in streptokinase arm• 2hr infusion regimens of streptokinase (1.5 million
units), urokinase and rt-PA (100 mg) followed by a heparin infusion have similar efficacy & safety
• Meta-analysis: in trials including massive PE & cardiac shock, thrombolysis a/w significant reduction in death and recurrent PE compared w/ heparin
• ICOPER: of those w/ masive PE (n=108): no difference in mortality or PE recurrence @ 90 days between thrombolysis vs heparin
Treatment: Medicine
• Risk of bleeding!• Contraindications: intracranial mass, h/o ICH, CVA
or neurosurgical procedure within past 2 months, recent major trauma, severe uncontrolled HTN, ongoing suspicion for aortic dissection, active or recent respiratory/GI/GU bleeding…
• ICOPER: risk of ICH up to 3%
Kucher et al. Circulation 2006;113, 577-582.
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Treatment: IR• Consider if contraindications
against systemic thrombolysis or it has already failed
• Catheter-assisted embolectomy: low-dose ‘local’ fibrinolysis and thrombus fragmentation or aspiration
• Mechanical disruption of clot brings more surface area of clot in contact with thrombolytic agent
• Systematic review (15 trials, n=594): clinical success rate 86.5% w/ low rates of complications
Kuo et al. J Vasc Interv Radiol 2009;20, 1431-1440.
Treatment: IR
Uflacker et al. J Vasc Interv Radiol 1996;7: 519-528.Lohan et al. Emerg Radiol 2007;13:161-169.
• Grade 1: fresh clot recently embolized, usually responds well to mechanical thrombectomy w/ increased flow & Oxygenation
• Grade 2: older, more organized clot; more residual clot likely to remain but still good chance of significant improvement in pulmonary flow
• Grade 3: old, organized chronic PE w/ recent worsening of acute-on-chronic PE; do not respond well to mechanical thrombectomy (need device that can scrape clot from vessel wall)
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Treatment: Surgical Embolectomy
• Consider after failed fibrinolysis; effective with large centrally located thrombi
• Invasive: requires median sternotomy and cardiopulmonary bypass
• 1994 case series: surgical success 85% w/ 23% mortality vs medical therapy success rate of 75% & 33% mortality
Gulba et al. Lancet 1994;343, 576-577.
Summary: Massive PE
• Suspected PE w/ cardiogenic shock and/or persistent arterial hypotension: weight-based UFH bolus first as continue workup
• If PE confirmed on imaging (CT/TTE), give thrombolytics
• If failed or contraindication to thrombolytics, consult IR/CT Surg for catheter-based thrombolysis or surgical embolectomy
Konstantinides. N Engl J Med 2008;359:2804-13.
“Doc, I have renal failure!”
• If renal failure or contrast allergy, V/Q scans are alternative imaging mode
• Helpful if normal: negative predictive value of 97%