Trombectomía mecánica en la tromboembolia pulmonar aguda de riesgo intermedio-alto / Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk

Introducción y objetivo:El tratamiento de la tromboembolia pulmonar (TEP) aguda con riesgo de mortalidad intermedio-alto a los 30 días, sigue sin estar bien definido, recomendándose por las últimas guías clínicas de la European Society of Cardiology2019 el tratamiento anticoagulante exclusivamente, reduciendo la indicación de trombectomía mecánica a pacientes de riesgo alto o pacientes con riesgo intermedio-alto con mala evolución hemodinámica. Nuestro objetivo fue comprobar la mejoría ecocardiográfica, respiratoria y hemodinámica en las primeras horas de los pacientes sometidos a trombectomía mecánica con tromboembolia pulmonar de riesgo intermedio-alto.Material y métodos:Se analizó la evolución cardíaca por ecocardiografía (diámetro de ventrículo derecho, TAPSE, Onda S e hipertensión pulmonar), hemodinámica, respiratoria y clínica de los pacientes en las primeras 24 horas tras trombectomía mecánica por aspiración, así como las complicaciones hemorrágicas y mortalidad del procedimiento.Resultados:Se llevaron a cabo 42 trombectomías mecánicas, 16 con inestabilidad hemodinámica (TEP masivo) y 26 estables hemodinámicamente (TEP submasivo). Se obtuvo mejoría (p<0,05) en el diámetro de ventrículo derecho, TAPSE, Onda S y presión arterial oxígeno/fracción inspiratoria de oxígeno (PaFi). Ocho pacientes recibieron tratamiento fibrinolítico, presentando 4 de ellos (50%) complicaciones hemorrágicas. Solo un paciente presentó complicación directa por el procedimiento (rotura arteria pulmonar). Ocho pacientes fallecieron en la fase aguda de la enfermedad.Conclusiones:La trombectomía mecánica por aspiración es una técnica segura y efectiva, observando una mejoría de la situación respiratoria, hemodinámica y ecocardiográfica de los pacientes en las primeras 24 horas postprocedimiento con baja tasa de complicaciones frente al tratamiento fibrinolítico. (AU)

Introduction and purpose:The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE).Methods:We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S′ wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality.Results:In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S′ wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase.Conclusions:Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis. (AU)

[Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk]. / Trombectomía mecánica en la tromboembolia pulmonar aguda de riesgo intermedio-alto.

INTRODUCTION AND PURPOSE: The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE). METHODS: We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S' wave, and pulmonary hypertension), respiratory parameters (PaO2/FiO2 ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality. RESULTS: In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S' wave, andPaO2/FiO2 ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase. CONCLUSIONS: Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis.

Etiology and Prognosis of Pneumonia in Patients with Solid Tumors: A Prospective Cohort of Hospitalized Cases.

BACKGROUND: Data on the incidence, etiology, and prognosis of non-ventilator-associated pneumonia in hospitalized patients with solid tumors are scarce. We aimed to study the characteristics of non-ventilator-associated pneumonia in hospitalized patients with solid tumors. MATERIALS AND METHODS: This was a prospective noninterventional cohort study of pneumonia in patients hospitalized in an oncology ward in a tertiary teaching hospital. Pneumonia was defined according to the American Thoracic Society criteria. Patients were followed for 1 month after diagnosis or until discharge. Survivors were compared with nonsurvivors. RESULTS: A total of 132 episodes of pneumonia were diagnosed over 1 year (9.8% of admissions to the oncology ward). They were health care-related (67.4%) or hospital-acquired pneumonia (31.8%). Lung cancer was the most common malignancy. An etiology was established in 48/132 episodes (36.4%). Knowing the etiology led to changes in antimicrobial therapy in 58.3%. Subsequent intensive care unit admission was required in 10.6% and was linked to inappropriate empirical therapy. Ten-day mortality was 24.2% and was significantly associated with hypoxia (odds ratio [OR], 2.1). Thirty-day mortality was 46.2%. The independent risk factors for 30-day mortality were hypoxia (OR, 3.3), hospital acquisition (OR, 3.1), and a performance status >1 (OR, 2.6). Only 40% of patients who died within 30 days were terminally ill. CONCLUSION: Pneumonia is a highly prevalent condition in hospitalized patients with solid tumors, even with nonterminal disease. Etiology is diverse, and poor outcome is linked to inappropriate empirical therapy. Efforts to get the empirical therapy right and reach an etiological diagnosis to subsequently de-escalate are warranted. IMPLICATIONS FOR PRACTICE: The present study shows that pneumonia is a prevalent infectious complication in patients admitted to oncology wards, with a very high mortality, even in non-terminally ill patients. Etiology is diverse, and etiological diagnosis is reached in fewer than 40% of cases in nonintubated patients. Intensive care unit admission, a marker of poor outcome, is associated with inappropriate empirical therapy. These results suggest that, to improve prognosis, a more precise and appropriate antimicrobial empirical therapy for pneumonia in patients with solid tumors is necessary, together with an effort to reach an etiological diagnosis to facilitate subsequent de-escalation.

Endobronchial cryotherapy for a mycetoma.

Mycetoma is defined as a fungus ball that fills a preexisting lung cavity, most frequently being of tuberculous or sarcoid etiology. The most frequently isolated fungus is the species of Aspergillus, but other fungi such as Fusarium or Zygomycetes can also be present. Most patients lack symptoms. However, presentation may also be with hemoptysis, which can be massive and life-threatening. We describe the case of a 50-year-old man with a history of prior pulmonary tuberculosis, with recurrent episodes of cough and hemoptysis. He was diagnosed to have mycetoma in the left upper lobe cavity. The mycetoma was extracted through bronchoscopy under general anesthesia using a cryoprobe. Treatment was completed with amphotericin B instilled in the cavity and the patient was placed on oral itraconazole. This is the first case report to date in which cryotherapy was used to remove a mycetoma.

Use of an endoscopy face mask in patients with gastric distention undergoing noninvasive ventilation for acute respiratory failure: a comparative case study report.

We describe the use of an endoscopy face mask with a perforated membrane, which allows a nasogastric tube for continuous noninvasive ventilation in acute hypercapnic respiratory failure, in 2 patients who developed gastric distention. This interface was able to avoid most nonintentional leaks through the mask, as compared with a conventional approach, improving ventilation efficiency. To our knowledge, this is the first case report of an endoscopy face mask used in noninvasive ventilation for this specific side effect.