[Catheter-assisted local lysis therapy for submassive pulmonary embolism]. / Kathetergestützte lokale Lysetherapie bei submassiven Lungenembolien.

BACKGROUND: Pulmonary embolism is the third most common cardiovascular disease. Interventional treatment options as an alternative to systemic lysis therapy of hemodynamically stable, submassive pulmonary embolisms have received an unprecedented boost in innovation in recent years. The treatment options are heterogeneous and can be roughly divided into local thrombolysis and local thrombectomy. For years in our center we have been carrying out catheter-assisted, locoregional lysis therapy with side-hole lysis catheters and a cumulative dose per pulmonary branch of 10 mg alteplase over 15 h for hemodynamically stable, submassive pulmonary emboli. AIM: The aim of this retrospective study was to review this therapeutic concept and to collect data on clinical endpoints and possible complications. METHODS: The study included data from 01/2018-03/2023. For this purpose, the patients were selected based on the OPS codes (8.838.60 and 1­276.0), and the data was collected using the medical records. Biometric data, data on previous illnesses and vital parameters, laboratory chemistry data, CT diagnostic data, echocardiographic data, data on drug treatment and data on complications were collected anonymously. RESULTS: There was a significant reduction in the strain on the right heart. Peripheral oxygen saturation also improved significantly and heart rate decreased significantly. The complication rate remained low and was almost exclusively limited to access-related problems. CONCLUSION: Catheter-assisted, locoregional lysis therapy is a safe and effective treatment method for submassive pulmonary embolism.

Persistent Peril: Recurrent Deep Vein Thrombosis and Pulmonary Embolism in a Patient With Protein S Deficiency Despite Optimal Anticoagulation Therapies.

The clotting system has evolved as an adaptive mechanism to prevent blood loss during vascular damage. However, the intricate nature of the clotting cascade and the complexities of human life can sometimes lead to the unnatural activation of this delicate cascade. This can result in blood clot formation within the cardiovascular system, contributing to a wide range of pathological conditions. Abnormal intravascular coagulation most commonly occurs in the deep veins of the lower extremities, and can emboli to other organs, hence, it is termed "venous thromboembolism" (VTE). In this report, we introduce a challenging case of VTE that poses a dilemma for current medical management. The patient with possible protein S deficiency underwent various guideline-directed medical treatments, yet experienced recurrent VTE episodes, including deep vein thrombosis (DVT) and pulmonary embolism (PE), leading to hospital readmissions. This case report sheds light on our challenges in effectively treating VTE.

Emergency Ultrasound Unveils Intermediate-High Risk Saddle Pulmonary Embolism with Extensive Bilateral Clot Burden, Masquerading as Micturition Syncope: A Case Report.

BACKGROUND: Isolated syncope as the manifestation of pulmonary embolism (PE) is a rare and diagnostically challenging presentation that often leads to delayed or missed diagnosis, increasing morbidity and mortality. In spite of emphasizing cardiovascular etiologies of syncope, current guidelines offer essentially no guidance in establishing a diagnostic workup for PE in these patients. By performing bedside echocardiography, emergency physicians can accurately identify concerning features suggestive of PE in patients with syncope. CASE REPORT: A 78-year-old man, receiving ertapenem via a peripherally inserted central catheter for treatment of extended spectrum ß-lactamase urinary tract infection, presented to the emergency department for isolated syncope with collapse while urinating. Arriving asymptomatic with normal vital signs and a benign physical examination, a presumptive diagnosis of micturition syncope was made. However, subtle vital sign changes on reassessment prompted performance of a point-of-care echocardiogram, which revealed signs of right heart strain. A computed tomography angiogram confirmed a saddle PE with extensive bilateral clot burden. Catheter-directed thrombectomy was performed via interventional radiology, with successful removal of pulmonary emboli. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Pulmonary embolism presenting as isolated syncope represents a daunting diagnostic dilemma, as emergency physicians may not consider it, or anchor on more benign etiologies of syncope. Although lacking sufficient sensitivity to rule out PE, point-of-care echocardiography to evaluate for signs of right heart strain can quickly and effectively point toward the diagnosis, while also assessing for other emergent cardiovascular causes of syncope. Given the lack of evidence-based guidance concerning PE presenting as syncope, bedside echocardiography should be highly considered as a part of the emergency physician's diagnostic workup, especially in patients with abnormal vital signs.

Pulmonary Embolism Triage: When to Do What.

Anticoagulation has been the standard therapy for treating pulmonary embolism. However, newly developed pharmacological and interventional treatment options have been shown to provide benefit for certain patient populations, depending on how they present. This column highlights the use of massive pulmonary embolism risk stratification in determining the presence of cor pulmonale and offers several key points to remember when caring for patients with a pulmonary embolism.

Navigating Diagnostic Challenges: Severe Pulmonary Hypertension in Acute Exacerbation of Chronic Obstructive Pulmonary Disease vs. Pulmonary Embolism.

A 63-year-old male with an unremarkable medical history presented to the emergency room (ER) with shortness of breath and bilateral lower extremity edema. In the ER, he was found to be hypoxic and hypercapnic on an arterial blood gas. CT angiography of the chest revealed severe emphysematous changes and large right apical bullae. A bedside point-of-care ultrasound demonstrated many bilateral B-lines as well as normal ejection fraction (EF). An echocardiogram revealed a small left ventricular cavity with an EF of 65%, severely dilated right ventricle, severe right ventricular dysfunction, "D" shaped interventricular septum, severely dilated right atrium, and severe pulmonary arterial hypertension (PAH) with a calculated pulmonary artery systolic pressure of 72 mmHg. The patient was initiated on bilevel positive airway pressure, glucocorticoids, bronchodilator nebulization, and diuretics with symptomatic improvement. Herein, this case report discusses similarities and differences between presentations and echocardiographic manifestations of severe PAH in the setting of acute exacerbation of chronic obstructive pulmonary disease and pulmonary embolism in the acute setting.

Severe Acute Cor Pulmonale With Impending Shock: An Insidious Incidental.

The S1Q3T3 sign associated with cor pulmonale was first described by Sylvester McGinn and Paul White in 1935. It has since become an overlooked and relatively nonspecific finding associated with pulmonary embolism. We present this case to elucidate the importance for clinicians to promptly identify this electrocardiographic triad.

Is there an OAHI or O2 nadir that predicts the need for preoperative echocardiogram prior to adenotonsillectomy for children with severe obstructive sleep apnea?

PURPOSE: To investigate threshold values for obstructive apnea-hypopnea index (OAHI) and nadir oxygen saturation (NspO2) in children with severe obstructive sleep apnea (OSA) to identify children most appropriate for preoperative echocardiography. METHODS: A multi-institutional retrospective chart review was performed on children who underwent echocardiography and polysomnogram within a year. Children with severe OSA as defined by OAHI > 10 or NspO2 < 80% were included. Receiver operator curves and Youden's J index were used to assess the discriminatory ability and threshold values of OAHI and NspO2 for right heart strain (RHS) on echocardiography. RESULTS: A total of 173 prepubertal (< 10 years) children and 71 postpubertal (≥ 10 years) children of age were included. RHS was seen in 9 (5%) prepubertal children and 4 (6%) postpubertal children. In prepubertal children, OAHI and NspO2 were poor predictors of RHS (area under the curve [AUC] 0.53 [95%CI 0.45-0.61], p = 0.748; AUC 0.56 [95%CI 0.48-0.64], p = 0.609). In postpubertal children, threshold values of 55 events/hour and 69% were strong predictors for RHS (AUC 0.88 [95%CI 0.78-0.95], p < 0.001; AUC 0.92 [95%CI 0.83-0.97], p < 0.001). CONCLUSION: In children with severe OSA, evidence of RHS is low. Postpubertal children with OAHI > 55 and NspO2 < 69% appear most appropriate for echocardiography. Clinicians should weigh the risks and benefits of preoperative echocardiography for each child with these threshold values in mind.

Right Ventricle Thrombus in the Setting of Submassive Pulmonary Embolism.

Submassive pulmonary embolism (PE) with right heart strain and right ventricle thrombus is a complex and potentially life-threatening condition. Prompt recognition and management are crucial to optimizing patient outcomes. We present the case of a 59-year-old male with a history of obstructive sleep apnea (OSA) and non-compliance with continuous positive airway pressure (CPAP) therapy who presented with progressively worsening shortness of breath (SOB). Imaging studies revealed bilateral submassive PE with right heart strain and a thrombus in the right ventricle. Treatment included anticoagulation therapy and mechanical thrombectomy using the INARI FlowTriever device. This case highlights the importance of early recognition and risk factor assessment, such as using testosterone boosters, considering right ventricle thrombus as a complication of PE, and the role of mechanical thrombectomy in selected cases.

Mechanical Thrombectomy of a Submassive Pulmonary Embolism in the Second Trimester of Pregnancy.

Venous thromboembolism (VTE) represents a potentially severe and infrequent complication that can occur in the pregnant population. The nuance in recognizing and diagnosing this condition can be quite difficult due to the changes that occur during pregnancy. This case highlights the importance of diagnosing pulmonary embolism in pregnancy, classifying the degree of disease, and determining the best treatment for both mother and fetus. Although rare, early diagnosis and treatment are crucial in order to reduce morbidity and mortality.

Right heart strain assessment on CTPA following acute pulmonary embolism: Interobserver variability between expert radiologists and physicians.

BACKGROUND: Accuracy of right heart strain (RHS) measured on computed tomography pulmonary angiogram (CTPA) scans by non-radiologists is unknown. We assessed inter-observer variability of four RHS features and determined the accuracy of measurements by respiratory physicians. METHOD: 1560 consecutive patients with acute PE were identified, and those who had a CTPA and an echocardiogram within 24-h included. CTPAs were independently scored prospectively by two radiologists, two thoracic physicians and a specialist registrar. Inter-observer variability was assessed, and diagnostic accuracy compared to echocardiography. RESULTS: 182 patients (median age 62.8 years, IQR 49.8-71.5) with acute PE (7.7% high-risk, 40.7% intermediate high-risk, 31.3% intermediate low-risk and 20.3% low-risk) were included. Right ventricle to left ventricle diameter ratio (RV:LV) measurement had low inter-observer variability among the radiologists and non-radiologists with interclass correlation coefficient (ICC) of 0.95 (95%CI 0.92-0.97) and 0.96 (95%CI 0.94-0.97) respectively. RV:LV ratio had high diagnostic accuracy compared to RV dilatation on echocardiography (AUC 0.89, 95%CI 0.84-0.94 for radiologists and AUC 0.84, 95%CI 0.77-0.90 for non-radiologists). Main pulmonary artery to ascending aorta diameter ratio (MPA:Ao) measurement also had excellent agreement amongst the radiologists and non-radiologists (ICC 0.93 (95%CI 0.88-0.96) and 0.92 (95%CI 0.81-0.96) respectively). Significant variability was seen in the assessment of subjective features of RHS (leftward bowing of interventricular septum and contrast reflux into inferior vena cava) amongst the non-radiologists. CONCLUSION: RV:LV and MPA:Ao diameter ratios on CTPA measured by non-radiologists have low inter-observer variability and good agreement with radiologists, and can be reliably used where an expert report is unavailable.

Changes in Lung Perfusion in Patients Treated with Percutaneous Mechanical Thrombectomy for Intermediate-Risk Pulmonary Embolism.

BACKGROUND: Current pulmonary embolism treatment options rely heavily on anatomical clot location. However, anatomical location does not necessarily determine adverse outcomes; rather, clinical severity is secondary to the degree of perfusion impairment. Dual-energy computed tomography pulmonary angiogram (DE-CTPA) can map perfusion at the time of pulmonary embolism diagnosis. Single-photon emission computed tomography ventilation-perfusion scans allow for perfusion tracking similar to DE-CTPA. METHODS: We present 3 patients with intermediate-risk pulmonary embolism treated with mechanical thrombectomy using the Inari FlowTriever System (Inari Medical, Irvine, Calif). Lung perfusion scoring was applied to pre-procedure and post-procedure imaging. We graded perfusion of each lobe in 3 planes. If the entire lobe was perfused, a score of 3 was assigned. If lung perfusion is normal, total perfusion score is 15. All patients had pre-procedure and follow-up transthoracic echocardiograms. RESULTS: All 3 patients were diagnosed with pulmonary embolism via DE-CTPA that showed right ventricle strain and had deep venous thrombosis. Following mechanical thrombectomy, patients immediately experienced improvement in perfusion score; scores continued to improve at follow-up. All patients also had improvement in right ventricle size or function on follow-up echocardiogram. DISCUSSION: Intermediate-risk pulmonary embolism often has large initial clot burden that predicts residual pulmonary vascular obstruction. Residual pulmonary vascular obstruction is associated with increased risk of death, recurrent thrombus, and chronic thromboembolic pulmonary hypertension. Clot removal via thrombectomy may decrease the prevalence of residual pulmonary vascular obstruction by improving lung perfusion. We found that mechanical thrombectomy increased lung perfusion immediately and at follow-up assessments.

Utilization of EKOS in Patients With Pulmonary Embolism.

Objective: Current guidelines recommend utilization of catheter-directed thrombolysis systems for management of patients with submassive pulmonary embolism (PE) who have relative contraindications to systemic thrombolysis. Evidence from previous trials have demonstrated the short-term efficacy and safety of one of these systems, the EkoSonic Endovascular System (EKOS). The objective of this study was to evaluate the long-term efficacy and safety of EKOS in submassive PE. Methods: This single-center, retrospective study evaluated subjects ≥18 years old with submassive PE and baseline right ventricular to left ventricular (RV/LV) diameter ratio ≥1. The primary outcome evaluated change in RV/LV diameter ratio from baseline to first follow-up. The secondary outcomes evaluated need for further intervention after EKOS, major bleeding within 72 hours and 6 months, all-cause mortality at 6 months, and all-cause 30-day readmission rate. Results: Overall, 41 subjects received EKOS for submassive PE. Of the 26 subjects evaluated for the primary outcome, the RV/LV diameter ratio decreased by an average of 0.56 (P < 0.05). Of the 41 subjects evaluated for the secondary outcomes, 1 subject required pulmonary embolectomy after EKOS intervention, 1 major bleed occurred within 72 hours, 1 major bleed occurred within 6 months, 1 subject died within 6 months, and 3 subjects were readmitted within 30 days. Conclusions: Intervention with EKOS further reduced right heart strain and resulted in few complications compared with previous trials providing evidence that EKOS is effective and safe long-term for management of submassive PE. Use should be considered in patients with relative contraindications to systemic thrombolytic therapy.

Pulmonary CTA Reporting: AJR Expert Panel Narrative Review.

Pulmonary CTA is a ubiquitous study interpreted by radiologists with different levels of experience in a variety of practice settings. Pulmonary embolism (PE) can range from an incidental and clinically insignificant finding to a clinically significant thrombus that can be managed on an outpatient basis to a potentially fatal condition requiring immediate medical or invasive management. Accordingly, a clear and concise pulmonary CTA report should effectively communicate the most pertinent findings to help the treating medical team diagnose or exclude PE and provide information to guide appropriate management. In this Expert Panel Narrative Review, we discuss the purpose of the radiology report for pulmonary CTA, the optimal report format, and the relevant findings that need to be addressed and their clinical significance.

Developing commotio cordis injury metrics for baseball safety: unravelling the connection between chest force and rib deformation to left ventricle strain and pressure.

Commotio cordis is a sudden death mechanism that occurs when the heart is impacted during the repolarization phase of the cardiac cycle. This study aimed to investigate commotio cordis injury metrics by correlating chest force and rib deformation to left ventricle strain and pressure. We simulated 128 chest impacts using a simulation matrix which included two initial velocities, 16 impact locations spread across the transverse and sagittal plane, and four baseball stiffness levels. Results showed that an initial velocity of 17.88 m/s and an impact location over the left ventricle was the most damaging setting across all possible settings, causing the most considerable left ventricle strain and pressure increases. The impact force metric did not correlate with left ventricle strain and pressure, while rib deformations located over the left ventricle were strongly correlated to left ventricle strain and pressure. These results lead us to the recommendation of exploring new injury metrics such as the rib deformations we have highlighted for future commotio cordis safety regulations.

A Case of Chronic Pulmonary Embolism Resulting in Pulmonary Hypertension and Decompensated Right Heart Failure.

Chronic thromboembolic pulmonary hypertension is a deadly condition that results from thrombus organization and formation of fibrous tissue in the large and/or middle-sized pulmonary artery; as a result, pulmonary vascular resistance increases resulting in pulmonary hypertension and right heart failure. Untreated chronic pulmonary embolism causes decompensated right heart failure. Early diagnosis and appropriate treatment are crucial for improving survival. Pulmonary endarterectomy (PEA) is the treatment of choice as it reduces pulmonary vascular resistance. For patients who are not a candidate for PEA, alternative treatment options improve quality of life.

Newly acquired complete right bundle branch block early after heart transplantation is associated with lower survival.

AIMS: Right bundle branch block (RBBB) after heart transplantation (HTX) is a common finding, but its impact on post-transplant survival remains uncertain. This study investigated the post-transplant outcomes of patients with complete RBBB (cRBBB) ≤ 30 days after HTX. METHODS: This registry study analysed 639 patients receiving HTX at Heidelberg Heart Center between 1989 and 2019. Patients were stratified by diagnosis of cRBBB ≤ 30 days after HTX. Analysis included recipient and donor data, medication, echocardiographic features, graft rejections, atrial fibrillation, heart rates, permanent pacemaker implantation and mortality after HTX including causes of death. RESULTS: One hundred thirty-nine patients showed cRBBB ≤ 30 days after HTX (21.8%), 20 patients with pre-existing cRBBB in the donor heart (3.2%) and 119 patients with newly acquired cRBBB (18.6%). Patients with newly acquired cRBBB had a worse 1-year post-transplant survival (36.1%, P < 0.01) compared with patients with pre-existing cRBBB (85.0%) or without cRBBB (86.4%), along with a higher percentage of death due to graft failure (P < 0.01). Multivariate analysis indicated cRBBB ≤ 30 days after HTX as significant risk factor for 1-year mortality after HTX (HR: 2.20; 95% CI: 1.68-2.87; P < 0.01). Secondary outcomes showed a higher rate of an enlarged right atrium (P = 0.01), enlarged right ventricle (P < 0.01), reduced right ventricular function (P < 0.01), 30-day atrial fibrillation (P < 0.01) and 1-year permanent pacemaker implantation (P = 0.02) in patients with cRBBB after HTX. CONCLUSIONS: Newly acquired cRBBB early after HTX is associated with increased post-transplant mortality.

Right Heart Strain on Presenting 12-Lead Electrocardiogram Predicts Critical Illness in COVID-19.

OBJECTIVES: This study aimed to assess the association of new right heart strain patterns on presenting 12-lead electrocardiogram (RHS-ECG) with outcomes in patients hospitalized with COVID-19. BACKGROUND: Cardiovascular comorbidities and complications, including right ventricular dysfunction, are common and are associated with worse outcomes in patients with COVID-19. The data on the clinical usefulness of the 12-lead ECG to aid with prognosis are limited. METHODS: This study retrospectively evaluated records from 480 patients who were consecutively admitted with COVID-19. ECGs obtained at presentation in the emergency department (ED) were considered index ECGs. RHS-ECG was defined by any new right-axis deviation, S1Q3T3 pattern, or ST depressions with T-wave inversions in leads V1 to V3 or leads II, III, and aVF. Multivariable logistic regression was performed to assess whether RHS-ECGs were independently associated with primary outcomes. RESULTS: ECGs from the ED were available for 314 patients who were included in the analysis. Most patients were in sinus rhythm, with sinus tachycardia being the most frequent dysrhythmia. RHS-ECG findings were present in 40 (11%) patients. RHS-ECGs were significantly associated with the incidence of adverse outcomes and an independent predictor of mortality (adjusted odds ratio [adjOR]: 15.2; 95% confidence interval [CI]: 5.1 to 45.2; p < 0.001), the need for mechanical ventilation (adjOR: 8.8; 95% CI: 3.4 to 23.2; p < 0.001), and their composite (adjOR: 12.1; 95% CI: 4.3 to 33.9]; p < 0.001). CONCLUSIONS: RHS-ECG was associated with mechanical ventilation and mortality in patients admitted with COVID-19. Special attention should be taken in patients admitted with new signs of RHS on presenting ECG.

Technical efficiency, short-term clinical results and safety of a large-bore aspiration catheter in acute pulmonary embolism - A retrospective case study.

BACKGROUND: Mechanical thrombectomy plays an important role in the management of acute pulmonary embolism (PE), either when rapid clot dissolution is needed or when thrombolytics are contraindicated. We describe our clinical and technical experience with the FlowTriever mechanical thrombectomy device in patients with acute PE. MATERIALS AND METHODS: A retrospective analysis was performed on all cases of acute PE treated with the FlowTriever device at a single tertiary care hospital system during the trial period (November 2019-January 2020). Technical and clinical results, including complications, are reported. RESULTS: Technical success was achieved in all eight successive cases (seven cases of submassive and 1 case of massive PE). Mean pulmonary artery pressure (MPAP) improved significantly after mechanical thrombectomy (27.8 ± 6.4 mmHg preprocedure; 20.5 ± 3.8 mmHg postprocedure; 7.3 ± 5.2 mmHg decrease after the procedure; P = 0.016). Hemoglobin levels did not change significantly after mechanical thrombectomy (11.8 g/dl ± 3.4 preprocedure; 9.9 g/dl ± 2.1 postprocedure; P = 0.20). Reduction in MPAP was achieved in 88% of cases (7/8) and hypoxia improved in all the nonintubated patients (7/7). Mortality observed in one patient with a massive central PE, was not related to the procedure. No mortality or procedural complications were observed in patients with submassive PE. CONCLUSIONS: The positive initial clinical experience and safety profile using the FlowTriever in the treatment of acute PE suggests, it has the potential to fill the unmet needs of a good mechanical thrombectomy device to treat massive and submassive high-risk PE especially when thrombolytics are contraindicated.

Successful aspiration thrombectomy in a patient with submassive, intermediate-risk pulmonary embolism following COVID-19 pneumonia.

A 64-year-old female patient presented with severe dyspnea shortly after apparent recovery from COVID-19 disease. Chest computed tomography revealed central pulmonary embolism and ultrasonography showed a deep vein thrombosis of her right leg. The patient was tachycardiac with evidence of right ventricular strain on echocardiography. An interdisciplinary decision for interventional therapy was made. Angiographic aspiration thrombectomy resulted in a significant reduction of thrombus material and improved flow in the pulmonary arteries and immediate marked clinical improvement and subsequent normalization of functional echocardiographic parameters. This case adds to the emerging evidence for severe thromboembolic complications following COVID-19 and suggests aspiration thrombectomy can be considered in pulmonary embolism of intermediate risk.