[Exercise deep venous thrombosis: myth or reality? About three cases of pulmonary embolism in long-distance runners]. / Maladie thromboembolique veineuse d'effort: mythe ou réalité? A propos de trois cas d'embolies pulmonaires chez des coureurs de fond.

The most frequent manifestation of exercise deep vein thrombosis (DVT) is the one occurring in upper limbs, in some specific and stereotypic conditions, sometimes complicated by pulmonary embolisms. A few cases of lower limbs DVT are reported in athletes. Some pathophysiologic arguments (rheological modifications, parietal lesions and coagulation abnormalities) suggest a link between DVT and exertion, but the causality is sometimes difficult to establish. We report three cases of pulmonary embolism occurring after a prolonged effort of running in trained marathon athletes. To our knowledge, very few similar cases have ever been reported. The possible responsibility of such physical efforts is discussed, as well as other potential cofactors such as coagulation abnormalities and hormonal contraception.

[Effects of delay in onset of revascularisation strategies in the acute phase of myocardial infarction]. / Place du délai de prise en charge dans la stratégie de revascularisation à la phase aiguë de l'infarctus du myocarde. Données issues de la vie réelle.

BACKGROUND: thrombolysis (THL) and primary percutaneous coronary intervention (PCI) are therapeutic options in acute myocardial infarction (MI). These strategies have similar efficiency, particularly in the early phase. However, in these randomized studies, different times to treatment (TT) threshold are recognized as discriminant. OBJECTIVES: to validate, on a one year mortality criteria the best TT threshold in the real life. METHODS: 794 patients, admitted directly in our institution with a Ml< or =12 hours; 299 were treated by THL and 495 by PCI. The primary end-point was 1-year mortality according to TT and strategy of revascularization. Three TT thresholds were tested (120, 150 and 180 min) to define the best strategy of revascularisation. RESULTS: only the 150 min TT threshold showed a significant difference between the two strategies. If TT was less than 150 min, relative risk of 1-year mortality was 1.36 (p=0.62) for patients treated by THL compared to those treated with PCI. By contrast, the relative risk of one year mortality was 1.95 if Tr was greater than 150 min (p=0.02). CONCLUSION: TT is a key factor to define the best strategy of reperfusion. The critical threshold seems to be at 150 min. THL should be considered as a therapeutic choice only if administered within the first 150 min. After this delay, primary PCI should be preferred.

Free-floating thrombus and embolic risk in patients with angiographically confirmed proximal deep venous thrombosis. A prospective study.

BACKGROUND: A free-floating thrombus (FFT) is often considered to be a risk factor for pulmonary embolism (PE), despite adequate anticoagulation therapy, in patients with proximal deep venous thrombosis. METHODS: Ninety-five patients underwent prospective assessment according to the presence (FFT group [n = 62]) or absence (occlusive thrombus group [n = 28]) of an FFT. On day 1, color venous duplex scanning, venography (reference method), perfusion lung scanning, and, if results of the lung scan were abnormal, pulmonary angiography were performed. On day 10 (range, days 9-11), the lung scan was repeated, as well as pulmonary angiography if the lung scan demonstrated impairment. A 3-month clinical follow-up visit was scheduled. Five patients were retrospectively excluded from analysis for uncertain diagnosis of FFT. Patients were treated with intravenous unfractionated heparin sodium adjusted for activated partial thromboplastin time (n = 1) or subcutaneous low-molecular-weight heparin (n = 89) (nadroparin calcium, 225 Institut Choay factor Xa inhibitory units per kilogram for 12 hours). Warfarin sodium therapy was initiated on day 3 (range, days 2-4). RESULTS: Both groups were well-matched according to age, sex, risk factors, and delay from onset of symptoms to treatment. Positive and negative predictive values of color venous duplex scanning for the diagnosis of an FFT were 91% and 55%, respectively. On admission, PE prevalence was 64% in the FFT group (40 of 62 patients) and 50% in the occlusive thrombus group (14 of 28 patients) (P = .19). Two patients were excluded on follow-up analysis (range, days 9-11) for preventive vena cava filtering (due to major bleeding in 1 and cholecystectomy in the other); the recurrent rate of PE was 3.3% in the FFT group (2 of 61 patients) and 3.7% in the occlusive thrombus group (1 of 27 patients). No symptomatic recurrent PE occurred between day 10 (range, days 9-11) and 3 months. Four patients died of evolutive neoplasm after hospital discharge. CONCLUSIONS: No higher risk for PE was observed in patients with free-floating proximal deep venous thrombosis; anticoagulant therapy should prevent recurrent PE in such patients.

[Lympho-epithelial thymoma revealed by a cardiac tamponade]. / Thymome lympho-épithélial révélé par une tamponnade.

The authors report the case of a 62 year old patient admitted for a tamponade, revealing a mixed lympho-epithelial thymoma with invasion of the pericardium, the aorta and of the pulmonary arteria. The histological diagnosis was confirmed by a surgical biopsy performed after emergency pericardiocentesis. A neoadjuvant chemotherapy was administered followed by incomplete surgical resection and then a post operative radiotherapy. A local relapse was diagnosed at one year follow up by CT scan and a second line chemotherapy was administered. No further relapse occurred and patient was alive at four years.

[Angioplasty at the bifurcation of the anterior interventricular artery and diagonal artery]. / Angioplastie de la bifurcation de l'artère interventriculaire antérieure et de l'artère diagonale.

UNLABELLED: The IVA/diagonal coronary bifurcation is a high risk area for atheromatous disease. Major technical and strategic risks make the treatment of these lesions a real "challenge" for the interventional cardiologist: angioplasty-stenting and surgery are in direct competition. OBJECTIVES: the aim of this study was to determine the significance of interventional techniques in treating the IVA/diagonal bifurcation, drawing on the experiences of a cardiological haemodynamic laboratory and comparing these results with those obtained with the reference technique, represented by aorto-coronary bypass with the internal mammary artery. METHODS: this was a monocentric retrospective study of a series of 133 patients treated with angioplasty-stenting between January 1997 and December 2002 for a new IVA/Dg bifurcation lesion. Patients admitted for myocardial infarction were excluded. RESULTS: no matter which angioplasty revascularisation technique was used, the angiographic success rate was 95% with 3% occlusions of the diagonal artery. At six months, 72% of patients were asymptomatic, the rate of treated lesion revascularisation (TLR) was 21.9%. At one year 68.8% of patients were asymptomatic, and the TLR was 24.2%. The technique evolved during the six years, especially with the expansion of the radial approach and increasingly frequent use of the "kissing balloon"; at one year the TLR and the rate of major cardiac events was 31% in 1997 and 15% in 2002. CONCLUSIONS: angioplasty-stenting in this at-risk region is thus favourable, and gives results comparable with those of internal mammary/IVA bypass, save on the TLR. However, the development of stents "pre-formed" for the bifurcation and especially "active" endoprostheses could represent a solution to the delicate problem of restenosis.

Rapid haemodynamic improvement following saruplase in recent massive pulmonary embolism.

In a single centre pilot study, saruplase (20 mg bolus plus 60 mg infusion over 1 h) was administered to twenty patients with an angiographically documented recent massive pulmonary embolism: Miller index of at least 20 and mean pulmonary artery pressure of at least 20 mmHg. The lytic ability of saruplase to cause normalization of haemodynamic parameters over the first 12 h and reperfusion of pulmonary arteries at 24 h was assessed. A decrease of 25 +/- 10% in total pulmonary resistance was evident at 30 min. Haemodynamic parameters continued to improve with total pulmonary resistance decreasing by 29 +/- 8% and 40 +/- 11% at 1 and 12 h respectively. Relative improvement in Miller index 24 +/- 6 h after saruplase treatment was 38 +/- 9%. Two patients suffered recurrent pulmonary embolism, two severe bleeding events were observed. One patient died following a haemorrhagic stroke.

Subcutaneous low-molecular-weight heparin fragmin versus intravenous unfractionated heparin in the treatment of acute non massive pulmonary embolism: an open randomized pilot study.

Low-molecular-weight heparins have been extensively investigated in the treatment of deep venous thrombosis but limited data are available concerning their use in pulmonary embolism. In an open, pilot, randomized study, we compare the safety and efficacy of Fragmin, a low-molecular-weight heparin with those of unfractionated heparin in 60 patients with non massive pulmonary embolism (Miller Index < 20). Thirty one patients received unfractionated heparin intravenously and 29 received a fixed dose of 120 Anti-Xa IU/kg of Fragmin administered subcutaneously twice a day for 10 days. There was no pulmonary embolism recurrence nor major bleeding in either group during the treatment period. The decrease in pulmonary vascular obstruction on perfusion lung scan between day 0 and day 10 was 17 +/- 13% in the Fragmin group and 16 +/- 13% in the heparin group (NS). These results indicate that Fragmin may be a safe and effective treatment of submassive pulmonary embolism.

Thrombosis and thrombolysis in unstable angina.

Pathophysiology of unstable angina involves spasm, plaque rupture, activation of platelets, and coagulation. The incidence and frequency of intracoronary thrombus formation are presently under active assessment in order to establish the potential benefit of thrombolytic therapy. A preliminary study was conducted in patients admitted in our coronary care unit for unstable angina with typical clinical and electrocardiographic criteria and with early coronary angiogram. After exclusion of 4 patients with left main coronary stenosis or contraindications for thrombolysis, 16 patients received thrombolytic infusion and 14 underwent a second coronary angiogram. Seven patients had an intracoronary thrombus (6 nonocclusive, 1 occlusive) and at the second angiogram only 3 nonocclusive thrombi were modified (1 disappeared, 2 were reduced). Moreover, the quantitative Coronary Angiography Analysis System (CAAS) in the 11 cases suitable for analysis did not show any significant changes, especially in the Ambrose type IIB lesions. In-hospital clinical outcome was not influenced by thrombolytic therapy (5 ischemic recurrences, 1 fatal myocardial infarction, 4 emergency and 4 elective revascularization procedures). This short series is in agreement with the literature data. Only one third of patients with active unstable angina remains refractory to conventional therapy. The transient benefit of thrombolysis is limited to patients with demonstrated intracoronary thrombi. Clinical or angiographic improvement are not always in correlation and until now do not seem able to prevent short-term recurrences or the need for revascularization procedures.

Hemodynamic effects of bolus vs 2-h infusion of alteplase in acute massive pulmonary embolism. A randomized controlled multicenter trial.

Four centers participated in a double-blind study in which 53 patients with angiographically documented acute massive pulmonary embolism (baseline Miller index > or = 17/34 and mean pulmonary artery pressure > or = 20 mm Hg) were randomly assigned to treatment with either 0.6 mg/kg bolus injection of alteplase over 15 min with a maximum dose of 50 mg (bolus group; n = 36), or 100 mg of alteplase over 2 h (2-h group; n = 17). The primary objective was to compare the rapidity of resolution of pulmonary embolism as judged by the change in total pulmonary resistance (TPR) over the initial first hour. Further objectives were to evaluate the changes in TPR over the next 11 h and the degree of lung scan resolution at 20 to 28 h. At 1 h, TPR decreased by 29 +/- 17 percent in the bolus group and by 36 +/- 16 percent in the 2-h group (mean +/- SD; p = 0.19). Continuous monitoring of TPR revealed that this variable improved in both groups without significant intergroup differences over the 12-h study period, although TPR decreased initially faster in the 2-h group. At 20 to 28 h, the absolute improvements in the lung scan perfusion defect were 14 +/- 12 percent in the bolus group compared with 13 +/- 9 percent in the 2-h group, with no significant intergroup differences. Major bleeding occurred in one patient of the 2-h group (6 percent) and in three patients of the bolus group (8 percent) (p > 0.5). Four patients (three from the bolus group and one from the 2-h group) may have experienced recurrent pulmonary embolism during the hospital stay. Neither death nor intracranial bleeding occurred.

Thrombolysis or heparin therapy in massive pulmonary embolism with right ventricular dilation: results from a 128-patient monocenter registry.

STUDY OBJECTIVES: To assess the potential benefit of thrombolysis in patients with massive pulmonary embolism (PE) with stable hemodynamics and right ventricular dysfunction. DESIGN: Retrospective, cohort study. SETTING: University-based, tertiary referral medical center. PATIENTS: One hundred fifty-three consecutive patients with massive PE from January 1992 to December 1997 treated with heparin or thrombolysis. MEASUREMENTS AND RESULTS: Massive PE was confirmed by perfusion lung scan or pulmonary angiography. Right ventricular dysfunction was assessed by echocardiography (right ventricular/left ventricular [RV/LV] diastolic diameter ratio > 0.6) in all patients. In order to study a homogeneous population, 64 patients treated with thrombolysis (group 1) were matched on baseline RV/LV diameter ratio to 64 patients treated with heparin (group 2). Perfusion lung scan was repeated at day 7 to day 10. Mean relative improvement in perfusion lung scans was higher in group 1 than group 2 (54% vs 42%, respectively). PE recurrences were the same in both groups (4.7%; n = 3). There were no bleeding complications and no deaths in group 2. Conversely, in group 1, 15.6% (n = 10) of patients suffered from bleeding (4.7%; n = 3 with intracranial bleeding) and 6.25% (n = 4) of them died. CONCLUSIONS: The results of this monocenter registry do not support the indication for thrombolysis in patients suffering from massive PE with stable hemodynamics and right ventricular dysfunction. Appropriate therapy in such patients still remains unknown. Further prospective randomized trials should be performed.

[Effects of anistreplase on coronary patency in acute myocardial infarction]. / Effets de l'anistreplase sur la perméabilité coronaire dans l'infarctus du myocarde aigu.

Anistreplase or APSAC (anisoylated lys-plasminogen streptokinase activator complex) is a new, third generation thrombolytic agent with a long (90 minutes) elimination half-life, so that it can be administered by bolus intravenous injection over 2 to 5 minutes. In acute myocardial infarction anistreplase in doses of 30 units gives a coronary recanalisation rate of about 65 per cent and an early coronary patency rate of about 80 per cent. It is more effective than streptokinase on coronary patency, when given within 3 hours of onset of myocardial infarction. The time required for recanalisation to occur is short (25 to 45 minutes depending on the time elapsed before administration), and the early (24 hours) coronary reocclusion rate is low (about 5%). These results, together with the ease of administration of the drug, could make anistreplase the first-choice thrombolytic agent in the treatment of recent myocardial infarction, notably in general hospitals and mobile intensive care units.

[Fibrinolytics in venous thromboembolic disease]. / Place des fibrinolytiques dans la maladie veineuse thromboembolique.

Thromboembolic venous disease includes deep vein thrombosis of the lower limbs and pulmonary embolism, a common acute complication. The usual treatment is anticoagulation. Thrombolytic drugs are only used in severe cases. Of the thrombolytic agents and therapeutic protocols in use, alteplase 100 mg/2 hours seems to be the best compromise between the risk of bleeding and efficacy in reducing pulmonary resistances by 30 to 40% and relatively early pulmonary revascularisation of 40-50%. As in myocardial infarction, cerebral haemorrhage is the main complication and the risk is higher in elderly (over 70 years of age) patients who have undergone invasive procedures. Massive pulmonary embolism, defined by clinical criteria, is presently the only formal indication of thrombolysis in this context. In non-massive embolism with right ventricular dysfunction, thrombolysis could also be indicated in the absence of haemorrhagic risk. In deep vein thrombosis of the lower limbs, the role of thrombolysis is limited and controversial; in many cases, the risk of haemorrhage is greater than the potential benefits.

[Thrombi of the right heart. Value of thrombolytic therapy in mobile thrombi]. / Thrombus des cavités cardiaques droites. Intérêt de la thrombolyse dans le traitement des thrombi mobiles.

Seven patients with mobile right heart thrombi, 4 floating and 3 pediculated, were recensed between 1985 and 1990. Two patients were admitted for congestive cardiac failure (Group I) and 5 patients for pulmonary embolism (Group II). Both patients in Group I were treated with heparin without complications. In one case, the size of the thrombus decreased in 10 days whereas, in the second case, it disappeared within 8 days. In Group II, the first patient underwent successful thrombectomy. The other four patients were given thrombolytic therapy (UK = 2, rt-PA = 2) associated with appropriate doses of heparin. In the two patients given UK (3M units the first day followed by 1.2 M units per day for 4 days) the thrombus disappeared in the first 48 hours of treatment. One patient had a recurrent pulmonary embolism after 2 hours' treatment; both patients had a fall in haemoglobin of 3 cg/ml at the second day. The second patient died at the 5th day. In the two patients treated by rt-PA (100 mg/7 hours) the thrombus disappeared within 4 hours of starting therapy. One patient had a probable recurrent pulmonary embolism. Both patients had a fall in haemoglobin of 3 cg/ml at the 2nd day of treatment. Right heart thrombi are rare (168 cases in the literature of which 111 were mobile). The prognosis seems to be related to echocardiographic appearances: mortality of mural thrombi is about 4% compared with 50% in mobile thrombi. Very mobile "worm-like" masses are therapeutic emergencies because of the risk of embolism (about 68%).(ABSTRACT TRUNCATED AT 250 WORDS)

[Echocardiography in pulmonary embolism]. / L'échocardiographie dans l'embolie pulmonaire.

Transthoracic echocardiography rarely confirms a diagnosis of pulmonary embolism by visualizing a thrombus in the pulmonary artery or right heart chambers. However, easily observed morphological and Doppler abnormalities may result from acute pulmonary hypertension: dilatation of the right heart chambers, a very sensitive and reliable sign of severe pulmonary embolism when the ratio of the right/left ventricular dimension > 0.6: abnormal interventricular septal contraction, a very specific sign of massive pulmonary embolism, and increased systolic pulmonary artery pressure. Transthoracic echocardiography allows evaluation of the severity of pulmonary embolism but it is difficult to orientate treatment on Doppler echocardiographic data alone. Transoesophageal echocardiography is a sensitive, specific and well-tolerated investigative method for the detection of proximal emboli in patients with massive pulmonary embolism. The investigation is rapid and can be carried out at the bedside, allowing confirmation of the diagnosis in two thirds of cases and the institution of thrombolytic or surgical therapy without the need for pulmonary angiography. Doppler echocardiography is also useful for following up the haemodynamic changes and the regression of acute cor pulmonale after thrombolysis.

[Contribution of transesophageal echocardiography to the diagnosis of pulmonary embolism]. / Apport de l'échocardiographie transoesophagienne au diagnostic de l'embolie pulmonaire.

Between September 1992 and August 1993 transoesophageal echocardiography was undertaken in 30 patients with clinical and scintigraphic signs of pulmonary embolism. The diagnosis was confirmed by pulmonary angiography (1 patient had failure of venous puncture; 1 patient refused the investigation). The aim of this study was to assess the tolerance and to determine the diagnostic value of transoesophageal echocardiography in patients with suspected pulmonary embolism (PE). Two groups of patients were identified: Group 1: presence of thrombus in the pulmonary artery on transoesophageal echocardiography and group 2: absence of visible thrombus. The produce was well tolerated in all patients. In 21 cases (group 1) 21 thrombi were observed in the right pulmonary artery and 4 thrombi in the left pulmonary artery. The appearances were those of a mobile venous thrombosis in 20 cases (91%) and of clearcut amputation of the proximal segment of the right pulmonary artery in 1 case. No thrombus was detected in 9 patients (group 2). In group 1, the first clinical signs occurred 12 +/- 12 days and the latest signs 2 +/- 3 days before the investigation. One patient had a history of chronic bronchitis. Two patients had a history of PE but with no sign of chronic post-embolic cor pulmonale. Twenty patients underwent pulmonary angiography. Miller's index was 71 +/- 9% and obstruction of proximal pulmonary arteries was observed in 20 patients. In group 2, the PE was confirmed at angiography in 8 cases. The first clinical signs dated from 27 +/- 54 days and the latest signs were observed 6 +/- 4 days before investigation.(ABSTRACT TRUNCATED AT 250 WORDS)

[Partial pulmonary embolectomy without extracorporeal circulation. Apropos of a case]. / Embolectomie pulmonaire partielle sans circulation extracorporelle. A propos d'un cas.

The authors report a case of massive pulmonary embolism compromising the haemodynamic status of a 52 year old man with a formal contraindication to thrombolytic therapy. Unilateral pulmonary embolectomy was performed without cardiac pulmonary bypass, preceded by partial interruption of the inferior vena cava. Postoperative controls confirmed the success of the surgical procedure. Although the indications of surgical embolectomy are limited, especially without cardiopulmonary bypass, it may be considered for the treatment of certain cases of massive pulmonary embolism.

[Effects of preceding stable or unstable angina on hospital morbidity-mortality of myocardial infarction. Results of a continuous series of 1,910 patients]. / Influence de l'angor préalable stable ou instable sur la morbidité-mortalité hospitalière de l'infarctus du myocarde. Résultats d'une série continue de 1,910 patients.

The aim of this study was to determine the effect of preceding unstable angina on the short-term prognosis of myocardial infarction based on early complications: cardiac failure, cardiac rupture, ventricular septal defect, sustained ventricular tachycardia ventricular fibrillation and hospital mortality. A continuous series of 1,910 patients admitted with 7 days of myocardial infarction was analysed retrospectively. The patients were divided into two groups according to their previous coronary history: Group A (myocardial infarction preceded by unstable angina) and Group B (myocardial infarction without preceding unstable angina). Group B was subdivided into Group B1 (myocardial infarction de novo) and Group B2 (myocardial infarction with previous stable angina). The results showed that patients with previous unstable angina (Group A) had a lower hospital mortality (7.9%) than those without (Group B) (13.3%) (p = 00017), fewer cardiac ruptures (1.1 versus 2.9%, p = 0.03) and less ventricular fibrillation (2.6 versus 4.5%, p = 0.053). Subgroups analysis showed that patients with de novo myocardial infarction (Group B1) had more sustained ventricular tachycardia than those with previous stable angina (Group B2) (5.3 versus 2.7%, p = 0.04). The authors conclude that pre-infarction unstable angina, possibly by ischaemic pre-conditioning, is an independent factor of a better prognosis in myocardial infarction.

[Anticoagulant therapy in pulmonary embolism]. / Traitements anticoagulants dans l'embolie pulmonaire.

Venous thrombosis and pulmonary embolism are the two faces of thromboembolic disease. In over 90% of cases, the initial treatment of the pulmonary embolism is anticoagulant therapy, the necessity and efficacy of which were demonstrated over 30 years ago with a reduction of mortality of 25 to 6%. Intravenous heparin relayed rapidly (1st to 3rd day) is still the conventional treatment protocol. Heparin therapy adapted to the result of the activated cephalin time (two to three times the control value) and oral vitamin K antagonists with a dosage adapted to keep the International Normalized Ratio between 2 and 3 is the safest and most effective treatment to date. The efficacy is shown by the low rate of recurrency, about 5% under anticoagulant therapy, lethal recurrence being very rare (less than 1%), and safety is attested by the low rate of severe bleeding complications (3 to 5%). The introduction of low molecular weight heparin and the excellent results observed in the treatment of deep vein thrombosis will probably lead to rapid extension of its indications to mild or moderate but haemodynamically well-tolerated pulmonary embolism. Hirudine and heparinoids will probably be the next step in the treatment of pulmonary embolism.

[Pulmonary embolism: which thrombolytic should be chosen?]. / Embolie pulmonaire: quel thrombolytique choisir?

A consensus has been reached in the last few years on the validity of the indication of thrombolysis in patients with pulmonary embolism and signs of shock. In this situation, the treatment must be rapid and effective and assessed on the haemodynamic results in the initial hours. A randomised, multicentre, double-blind clinical trial has clearly shown the superiority of rtPA at the dose of 100 mg given in 2 hours over high dose prolonged urokinase, the fall in total pulmonary resistances being 36 and 18% (p = 0.0009) respectively at the second hour. With respect to the secondary effects, the risk of serious haemorrhage with rtPA does not seem to be less than that of the first generation thrombolytics, and the data of 22 published studies even shows an increased risk of cerebral haemorrhage with rtPA compared with urokinase (1.6 versus 0.5%). Recent experience has shown that bolus administration of rtPA does not improve either the efficacy or safety of this drug. Therefore rtPA (100 mg in 2 hours) is the drug of choice in patients with a low risk of haemorrhage whereas the elderly patients with low body weight and hypertensives should probably be treated with low dose urokinase given in bolus administration, the efficacy/risk ratio of which seems to be satisfactory.

[Comparative efficacy and risks of low molecular weight heparins and thrombolysis in massive pulmonary embolism without cardiogenic shock]. / Efficacité et risques comparés des héparines de bas poids moléculaire et de la thrombolyse dans l'embolie pulmonaire massive sans état de choc. A propos de 62 patients.

The aim of this retrospective study was to assess pulmonary reperfusion by scintigraphy, the risks of recurrent embolism and of bleeding complications at the 7th day and 3rd month in 2 groups of patients admitted to hospital for massive pulmonary embolism without cardiogenic shock treated by intravenous thrombolysis (Group I) and by subcutaneous low molecular weight heparin (Group II) paired by Miller's index. The basal characteristics of the two groups, each comprising 31 patients, were comparable with respect to the severity of the pulmonary embolism with an average global scintigraphic defect of 40.6 +/- 13.5% in Group I and 39 +/- 13.7% in Group II. The scintigraphic changes at the 7th day were comparable with a relative improvement of 55 and 51% respectively and at 3 months of 74% in both groups. There was no significant difference in terms of recurrence of embolism (3 versus 0% at the 7th day and 3% in each group at 3 months) or of bleeding complications (13 and 10% at the 7th day and 10 and 6% at 3 months respectively). Low molecular weight heparin seems to be as effective as intravenous thrombolysis for the treatment of massive pulmonary embolism without shock. This result requires confirmation by a large scale prospective randomised trial.