Increased incidence of venous thromboembolism associated with inferior vena cava filter placement in patients diagnosed with isolated calf deep vein thrombosis after intracranial hemorrhage or intracranial operation.

In this study, we sought to investigate the effectiveness of inferior vena cava (IVC) filter placement in reducing the incidence of venous thromboembolism (VTE) in patients diagnosed with isolated calf deep vein thrombosis (DVT) after an intracranial hemorrhage or intracranial operation. A retrospective chart review (January 2000-December 2019) was performed to identify patients diagnosed with calf DVT after intracranial hemorrhage or intracranial operation. A total of 100 patients met the study criteria and were divided into groups based on treatment: IVC filter placement (n = 22), prophylactic anticoagulation (n = 42), or imaging surveillance (n = 36). Treatment-related complications were identified, and differences between groups in the primary endpoint (VTE occurrence after DVT diagnosis) were assessed using logistic regression. VTE occurred in 15 patients after calf DVT diagnosis. The rate of VTE was higher in the IVC filter group (9/22; 41%) than in the anticoagulation (2/42; 5%; p = 0.002) and surveillance (4/36; 11%; p = 0.013) groups. These treatment effects remained significant after adjustments were made for baseline characteristics (IVC filter vs anticoagulation, p = 0.009; IVC filter vs surveillance, p = 0.019). There was a single occurrence of pulmonary embolism in the surveillance group (3%). A single case of IVC filter thrombus was identified; no anticoagulation-related complications were reported. The findings of this study do not support IVC filter placement as a primary and solitary treatment for isolated calf DVT occurring after intracranial hemorrhage or intracranial operation.

Thrombotic outcomes in patients in a large clinical enterprise following COVID-19 vaccination.

Vaccination against COVID-19 reduces infection-related mortality. Unfortunately, reports of vaccine-induced immune thrombotic thrombocytopenia (VITT) in individuals administered adenovirus-vector-based vaccines (ChAdOx1 nCoV-19 and Ad26.COV2.S) have spurred side effect concerns. To address vaccine hesitancy related to this, it is essential to determine the incidence of VITT (defined by a 50% decrease in platelet count and positive anti-PF4 immunoassay within 4-28 days after vaccination) among patients administered two doses of an mRNA-based COVID-19 vaccination. We identified a retrospective cohort of 223,345 patients in the Cleveland Clinic Enterprise administered a COVID-19 vaccine at any location in Northeast Ohio and Florida from 12/4/2020 to 6/6/2021. 97.3% of these patients received an mRNA-based vaccination. Patients with: (1) a serial complete blood count both before and after vaccination and (2) a decrease in platelet count of ≥ 50% were selected for chart review. The primary outcome was the incidence of thrombotic events, including venous thromboembolism (VTE) and arterial thrombosis, 4-28 days post vaccination. Of 74 cohort patients with acute thrombosis, 72 (97.3%) demonstrated clear etiologies, such as active malignancy. Of two patients with unprovoked thrombosis, only one had findings concerning for VITT, with a strongly positive anti-PF4 antibody assay. In this large, multi-state, retrospective cohort, of 223,345 patients (97.2% of whom received the mRNA-based mRNA-1273 or BNT162b2 vaccines), we detected a single case that was concerning for VITT in a patient who received an mRNA vaccine. The overwhelming majority of patients with a thrombotic event 4-28 days following vaccination demonstrated clear etiologies.

Predictors and potential advantages of PERT and advanced therapy use in acute pulmonary embolism.

OBJECTIVES: We sought to examine predictors of pulmonary embolism response team (PERT) utilization and identify those who could benefit from advanced therapy. BACKGROUND: PERT and advanced therapy use remain low. Current risk stratification tools heavily weight age and comorbidities, which may not always correlate with presentation's severity. METHODS: We prospectively studied patients with CT-confirmed PE between January 2019 and December 2019 at our hospital. PERT activation was left to the treating physician. Multivariable analyses were utilized to identify predictors of PERT activation and advanced therapy. Using the log odd ratio of each significant predictor of advanced therapy, we created a scoring system and a score of 2 was associated with the highest use. Primary outcomes were 30- and 90-day all-cause mortality, readmission, and major bleed. RESULTS: Of the 307 patients, PERT was activated in 22.5%. While abnormal vital signs and right ventricular (RV) strain were associated with PERT activation, pulmonary embolism severity index (PESI) was not. Advanced therapy use was significantly higher in the PERT cohort (35% vs 2%). Predictors of advanced therapy use were composite variable (heart rate > 110 or systolic blood pressure < 100 or respiratory rate > 30 or oxygen saturation < 90%) and right-to-left ventricular ratio > 0.9. PERT patients with advanced therapy use, when compared to the no-PERT patients who could have qualified (score of 2), had significantly lower 30- and 90-day mortality and 30-day readmission without difference in major bleed. CONCLUSION: PERT has important therapeutic impact, yet no guidelines to direct activation. We recommend a multidisciplinary approach for higher acuity pulmonary embolism cases and physician education regarding PERT and the scope of advanced therapy use.

Postoperative outcomes and management strategies for coronary artery disease in patients in need of a lung transplantation.

BACKGROUND: Patients requiring lung transplantation (LTx) may also have coronary artery disease (CAD). The peri-operative management and long-term outcomes of these patients are not well established. METHODS: Patients referred for LTx from 2008 to 2014 were included in this study. CAD was defined by angiography as no CAD (stenosis <20%), moderate CAD (20%-69%), and significant CAD (stenosis ≥70%). Revascularization was per recommendations of local heart team. Postoperative cardiovascular outcomes and long-term survival are reported. RESULTS: A total of 1493 patients were screened for LTx during this period and 656 received a transplant. Of the patients that underwent LTx, 51% had no CAD, 33% had moderate non-obstructive CAD, and 16% had obstructive CAD. Forty-three patients underwent revascularization. There was a no increased risk of peri-operative cardiovascular events or for adjusted mortality for patients with obstructive CAD (HR=1.24, 95% CI: 0.83-1.86, P=.290) including those requiring revascularization. CONCLUSIONS: There is a high prevalence of coronary disease in the population of patients with advanced lung disease requiring lung transplantation. Careful evaluation and treatment can allow for patients with all severities of CAD including those requiring revascularization to successfully undergo LTx.

The Obesity Mortality Paradox in Patients with Pulmonary Embolism: Insights from a Tertiary Care Center.

Background: While obesity is associated with an increased risk of venous thromboembolism (VTE), there is some data to suggest that higher BMI is also associated with decreased all-cause mortality in patients with a pulmonary embolism (PE). Methods: Using PE Response Team (PERT) activation data from a large tertiary hospital between 27 October 2020 and 28 August 2023, we constructed a multivariate Cox proportional hazards model to assess the association between obesity as a dichotomous variable (defined as BMI ≥ 30 vs. BMI 18.5-29.9), BMI as a continuous variable, and 30-day PE-related mortality. Results: A total of 248 patients were included in this analysis (150 with obesity and 98 who were in the normal/overweight category). Obesity was associated with a lower risk of 30-day PE-related mortality (adjusted HR 0.29, p = 0.036, 95% CI 0.09-0.92). A higher BMI was paradoxically associated with a lower risk of PE-related mortality (HR = 0.91 per 1 kg/m2 increase, p = 0.049, 95% CI 0.83-0.999). Conclusions: In our contemporary cohort of patients with a PERT activation, obesity was associated with a lower risk of PE-related mortality.

Mechanical thrombectomy for acute pulmonary embolism in lung transplant recipients.

The rates of pulmonary embolism (PE) are high among lung transplant (LT) recipients. Management is challenging because of elevated bleeding risks and inadequacy of conventional PE risk stratification tools. New percutaneous large bore mechanical thrombectomy catheters are being increasingly used effectively to debulk thrombus and restore flow immediately. We describe the use of mechanical thrombectomy (MT) in 8 LT recipients. All patients were diagnosed with intermediate/high-risk proximal PE involving the allograft and underwent successful MT within 30 hours of diagnosis. Estimated blood loss was between 200 and 450 cc, with 3 patients requiring blood transfusions. Improvement in heart rate and oxygenation was seen in all 8 patients after the procedure. In the 30 days after MT, 7 of 8 patients survived. One patient died from major bleeding occurred 16 days after MT and 5 days after venoarterial extracorporeal membrane oxygenator decannulation. Mechanical thrombectomy may provide a feasible management strategy in select LT recipients with pulmonary embolism.

Psychological distress in pulmonary embolism survivors in a pulmonary embolism response team clinic: Protocol for a prospective observational study.

Background: Pulmonary embolism (PE) is a leading cause of cardiovascular death. Psychological distress in PE is understudied and underrecognized. Objectives: The primary aim of this proposed protocol was to describe the incidence of psychological distress symptoms (anxiety, depression, posttraumatic stress, and fear of recurrence) in the survivors of PE after discharge from hospitalization. The secondary aim was to assess the influence of acute disease, etiology, and treatment of PE on psychological distress. Methods: This is a prospective observational cohort study in a large tertiary care referral center. The participants are adult patients presenting to the hospital with PE fulfilling objective pulmonary embolism response team (PERT) activation criteria. After discharge, patients complete a series of validated measures of psychological distress (anxiety, depression, posttraumatic stress, and fear of recurrence) and quality of life at follow-ups approximately 1, 3, 6, and 12 months after diagnosis and treatment of their PE. Factors influencing each type of distress are evaluated. Conclusion: This protocol aims to identify the unmet needs of patients experiencing psychological distress following PE. It will describe anxiety, depression, fear of recurrence, and posttraumatic symptoms in PE survivors during the first year of outpatient follow-up in a PERT clinic.

Case of right ventricular and aortic thrombi in a patient with severe COVID-19.

Emerging evidence suggests that novel COVID-19 is associated with increased prothrombotic state and risk of thromboembolic complications, particularly in severe disease. COVID-19 is known to predispose to both venous and arterial thrombotic disease. We describe a case of a 61-year-old woman with history of type II diabetes, hypertension and hyperlipidaemia who presented with dry cough and acute abdominal pain. She was found to have a significantly elevated D-dimer, prompting imaging that showed thrombi in her right ventricle and aorta. She had rapid clinical deterioration and eventually required tissue plasminogen activator with subsequent durable clinical improvement. This case highlights a rare co-occurrence of venous and arterial thrombi in a patient with severe COVID-19. Further studies are needed to clarify the molecular mechanism of COVID-19 coagulopathy, the utility of D-dimer to predict and stratify risk of thrombosis in COVID-19, and the use of fibrinolytic therapy in patients with COVID-19.

Simultaneous Pulmonary Artery Pressure and Left Ventricle Stroke Volume Assessment Predicts Adverse Events in Patients With Pulmonary Embolism.

Background Certain echocardiographic parameters may serve as early predictors of adverse events in patients with hemodynamically compromising pulmonary embolism (PE). Methods and Results An observational analysis was conducted for patients with acute pulmonary embolism evaluated by a Pulmonary Embolism Response Team (PERT) between 2014 and 2020. The performance of clinical prediction algorithms including the Pulmonary Embolism Severity Index and Carl Bova score were compared using a ratio of right ventricle and left ventricle hemodynamics by dividing the pulmonary artery systolic pressure by the left ventricle stroke volume. The primary outcome of in-hospital mortality, cardiac arrest, and the need for advanced therapies was evaluated by univariate and multivariable analyses. Of the 343 patients meeting the inclusion criteria, 215 had complete data. Pulmonary artery systolic pressure/left ventricle stroke volume was a clear predictor of the primary end point (odds ratio [OR], 2.31; P=0.005), performing as well or better than the Pulmonary Embolism Severity Index (OR, 1.43; P=0.06) or the Bova score (OR, 1.28; P=0.01). Conclusions This study is the first study to demonstrate the utility of early pulmonary artery systolic pressure/left ventricle stroke volume in predicting adverse clinical events in patients with acute pulmonary embolism. Pulmonary artery systolic pressure/left ventricle stroke volume may be a surrogate marker of ventricular asynchrony in high-risk pulmonary embolism and should be prognostically evaluated.

Prospective Experience of Pulmonary Embolism Management and Outcomes.

OBJECTIVE: We sought to evaluate the impact of pulmonary embolism (PE) response teams (PERTs) on all consecutive patients with PE. BACKGROUND: Multidisciplinary PERTs have been promoted for the management and treatment of (PE); however, the impact of PERTs on clinical outcomes has not been prospectively evaluated. METHODS: We prospectively studied 220 patients with computed tomography (CT)-confirmed PE between January, 2019 and August, 2019. Baseline characteristics, as well as medical, interventional, and operational care, were captured. The total population was divided into 2 groups, ie, those with PERT activation and those without PERT activation. PERT activation was left at the discretion of the primary team. Our primary outcome was 90-day composite endpoint (rate of readmission, major bleeds, and mortality). Using 2:1 propensity-matched and multivariable-adjusted Cox proportional hazard analyses, we examined the impact of PERT activation on primary outcome, treatment approach, and length of stay. RESULTS: Of the total 220 patients, PERT was activated in 47 (21.4%). The PERT cohort, as compared with the non-PERT cohort, was more likely to present with dyspnea, syncope, lower systolic blood pressure, higher heart rate, higher respiratory rate, lower oxygen saturation, higher troponin levels, and higher right ventricular to left ventricular ratio. PERT activation was associated with increased use of advanced therapies (36.2% vs 1.2%; P<.001) and catheter-directed inventions (25.5% vs 0.6%; P<.001). In multivariable-adjusted analysis of propensity-matched cohorts, PERT activation was associated with lower 90-day outcomes (hazard ratio, 0.40; 95% confidence interval, 0.21-0.75; P<.01). CONCLUSION: At our institution, PERT had a clinically significant impact on therapeutic strategies and 90-day outcomes in patients with PE.