Value of retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy in acute pulmonary embolism: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Acute pulmonary embolism is a serious cardiovascular disease with high mortality. Surgery is an important therapeutic means. The traditional surgical method is pulmonary artery embolectomy with cardiopulmonary bypass, but there is a certain recurrence rate after surgery. Some scholars use retrograde pulmonary vein perfusion as an adjunct to conventional pulmonary artery embolectomy. However, whether this method can be used safely for acute pulmonary embolism and its long-term effects remains unclear. Therefore, we plan to conduct a systematic review and meta-analysis to investigate whether retrograde pulmonary vein perfusion combined with pulmonary artery thrombectomy can be safely used in acute pulmonary embolism. METHODS AND ANALYSIS: We will search key databases (Ovid MEDLINE, PubMed, Web of Science, Cochrane Library, China Science and Technology Journals and Wanfang) for studies on acute pulmonary embolism treated with retrograde pulmonary vein perfusion from January 2002 to December 2022. The useful information will be consolidated into a piloting spreadsheet. The Cochrane Risk of Bias Tool will be used to assess the bias. Data will be synthesised and heterogeneity will be evaluated. The dichotomous variables will be determined by using risk ratio with 95% CI, and weighted mean differences (with 95% CI) or standardised mean differences (95% CI) will be used for continuous variables. Χ2 test and I2 test will be used to assess the statistical heterogeneity. Meta-analysis will be conducted when strong homogeneous data are accessible. ETHICS AND DISSEMINATION: Approval of the ethics committee is not needed for this review. While results will be disseminated electronically, effective dissemination will be done through presentations and peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD42022345812; pre-results.

Choledochoscope-guided treatment of pulmonary embolism caused by ventricular myxoma.

A 33-year male patient presented with a 6-month history of cough and shortness of breath upon physical activity. Echocardiography demonstrated right ventricular space-occupying lesions. Contrast-enhanced computed tomography of the chest showed multiple emboli in the pulmonary artery and its branches. Right ventricle tumor (myxoma) resection, tricuspid valve replacement, and clearance of the pulmonary artery thrombus were performed under cardiopulmonary bypass. Minimally invasive forceps and balloon urinary catheters were used to clear the thrombus. Clearance was confirmed by direct visualization using a choledochoscope. The patient recovered well and was discharged. The patient was prescribed oral warfarin 3 mg/day, and the international normalized ratio for prothrombin time was maintained between 2.0 and 3.0. Pre-discharge echocardiogram showed no lesion in the right ventricle or pulmonary arteries. The 6-month follow-up echocardiography indicated that the tricuspid valve was functioning well and showed no thrombus in the pulmonary artery.

First use of large-bore suction thrombectomy for acute pulmonary embolism in Asia-Pacific: feasibility and short-term clinical outcomes.

Clinical outcomes for intermediate or high-risk pulmonary emboli (PE) remain sub-optimal, with limited improvements in survival for the past 15 years. Anticoagulation alone results in slow thrombus resolution, persistent right ventricular (RV) dysfunction, patients remaining at risk of haemodynamic decompensation and increased likelihood of incomplete recovery. Thrombolysis elevates risk of major bleeding and is thus reserved for high-risk PE. Thus, a huge clinical need exists for an effective technique to restore pulmonary perfusion with minimal risk and avoidance of lytic therapy. In 2021, large bore suction thrombectomy (ST) was introduced in Asia for the first time and this study assessed the feasibility and short-term outcomes of Asian patients undergoing ST for acute PE. 40 consecutive patients (58% male, mean age of 58.3 ± 16.6 years) with intermediate (87.5%) or high-risk PE (12.5%) were enrolled in this prospective registry. 20% had prior VTE, 42.5% had contraindications to thrombolysis, and 10% failed to respond to thrombolysis. PE was idiopathic in 40%, associated with active cancer in 15% and post-operative status in 12.5%. Procedural time was 124 ± 30 min. Emboli were aspirated in all patients without the need for thrombolytics, resulting in a 21.4% reduction in mean pulmonary arterial pressures and 123% increase TASPE-PASP ratio, a prognostic measure of RV-arterial coupling. (both p < 0.001) Procedural complications were 5% and 87.5% patients survived to discharge without symptomatic VTE recurrence during 184 days of mean follow-up. ST affords an effective reperfusion option for PE without thrombolytics, normalises RV overload and provides excellent short-term clinical outcomes.

Pulmonary Vein Sign on Computed Tomography Pulmonary Angiography in Proximal and Distal Chronic Thromboembolic Pulmonary Hypertension With Hemodynamic Correlation.

BACKGROUND: Pulmonary vein sign (PVS) indicates abnormal pulmonary venous flow on computed tomography pulmonary angiography (CTPA) is a frequent finding in proximal chronic thromboembolic pulmonary hypertension (CTEPH). PVS's occurrence in distal CTEPH and correlation to disease severity is unknown. Using right heart catheterization data, we evaluated the relationship between PVS and CTEPH disease distribution and severity. MATERIALS AND METHOD: A total of 93 consecutive CTEPH cases with both CTPA and right heart catheterization were identified in this retrospective multi-institutional study. After excluding 17 cases with suboptimal CTPA, there were 52 proximal and 24 distal CTEPH cases. Blood flow in the major pulmonary veins was graded qualitatively. Subgroup analysis of PVS was performed in 38 proximal CTEPH cases before and after pulmonary endarterectomy. RESULTS: PVS was more frequent in proximal (79%) than distal CTEPH (29%) ( P <0.001). No significant difference was noted in invasive mean pulmonary artery pressure (46±11 and 41±12 mm Hg) or pulmonary vascular resistance (9.4±4.5 and 8.4±4.8 WU) between the 2 groups. In the subgroup analysis, PVS was present in 29/38 patients (76%) before surgery. Postoperatively, 33/38 cases (87%, P <0.001) had normal venous flow (mean pulmonary artery pressure 46±11 and 25; pulmonary vascular resistance 9.2±4.3 and 2.6 WU preop and postop, respectively). CONCLUSION: PVS is a common feature in proximal but infrequent findings in distal CTEPH. PVS does not correlate with hemodynamic severity. PVS resolution was seen in the majority of patients following successful endarterectomy.

Establishing a balloon pulmonary angioplasty program for chronic thromboembolic pulmonary hypertension: A United States single-center experience.

INTRODUCTION: Balloon pulmonary angioplasty (BPA) is a less invasive treatment alternative for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are unable to move forward with pulmonary thromboendarterectomy. This report describes a single-center experience with a nascent BPA program in the United States (US). METHODS: All patients who underwent BPA between August 2018-2021 were included in this retrospective, single-center observational cohort. Pre- and post-procedure clinical information was collected, along with procedural characteristics. RESULTS: Thirty patients began their BPA series during the study period. The majority of patients had segmental disease (n = 25, 83.3%). A total of 135 BPA procedures were performed on 417 segments. On average, patients completed 4.5 sessions and the majority of patients (n = 23, 76.7%) underwent more than 2. There were 24 episodes of hemoptysis and 20 procedural events that required treatment, typically with either heparin reversal or balloon tamponade. Of 26 participants with completed series, mean PA pressure (-6 mmHg, 95% CI -9 to -4 mmHg, p = 0.0001), PVR (-1.9 Wood units, 95% CI -2.9 to -1.0, p = 0.0002), and pulmonary compliance (-1.0 mL/mmHg, 95% CI -1.5 to -0.5, p = 0.0002) improved. Improvement was also seen in NYHA functional classification and walk distance (p = 0.01). Two deaths occurred, with one death peri-procedurally. CONCLUSION: This paper describes an early experience with BPA at a single US center. Improvement in non-invasive and invasive metrics were seen without adding a significant morbidity to an already high-risk patient population.

Contemporary interventional management of pulmonary embolism.

Minimally invasive interventional techniques are being utilised more frequently in the management of acute and chronic pulmonary emboli; however, robust clinical evidence is only emerging for the utilisation of these techniques. Hence, there is a need for a robust mechanism of patient selection and careful consideration of the benefits and risks of the interventions. In this review, we discuss the risk stratification mechanisms; the role of the multidisciplinary pulmonary embolism response team to support decision-making; and describe the various commonly used interventional techniques and how these can be integrated into treatment strategies for the benefit of our patients.

Aseptic revisions and pulmonary embolism after surgical treatment of femoral neck fractures with cemented and cementless hemiarthroplasty in Germany: an analysis from the German Arthroplasty Registry (EPRD).

BACKGROUND: Femoral neck fractures (FNF) are among the most common fractures in Germany and are often treated by hemiarthroplasty (HA). The aim of this study was to compare the occurrence of aseptic revisions after cemented and uncemented HA for the treatment of FNF. Secondly, the rate of pulmonary embolism was investigated. METHODS: Data collection for this study was performed using the German Arthroplasty Registry (EPRD). HAs after FNF were divided into subgroups stratified by stem fixation (cemented vs uncemented) and paired according to age, sex, BMI, and the Elixhauser score using Mahalanobis distance matching. RESULTS: Examination of 18,180 matched cases showed a significantly increased rate of aseptic revisions in uncemented HA (p < 0.0001). After 1 month 2.5% of HAs with uncemented stems required an aseptic revision, while 1.5% were reported in cemented HA. After 1 and 3 years' follow-up 3.9% and 4.5% of uncemented HA and 2.2% and 2.5% of cemented HA needed aseptic revision surgery. In particular, the proportion of periprosthetic fractures was increased in cementless implanted HA (p < 0.0001). During in-patient stays, pulmonary emboli occurred more frequently after cemented HA [0.81% vs 0.53% in cementless HA (OR: 1.53; p = 0.057)]. CONCLUSION: For uncemented hemiarthroplasties a statistically significantly increased rate of aseptic revisions and periprosthetic fractures was evident within a time period of 5 years after implantation. During the in-hospital stay, patients with cemented HA experienced an increased rate of pulmonary embolism, but without statistically significant results. Based on the present results, with knowledge of prevention measurements and correct cementation technique, cemented HA should be preferred when using HA in the treatment of femoral neck fractures. TRAIL REGISTRATION: The study design of the German Arthroplasty Registry was approved by the University of Kiel (ID: D 473/11). LEVEL OF EVIDENCE: Level III, Prognostic.

Cardiogenic shock due to pulmonary thromboembolism: the role of surgical thrombectomy.

A 53-year-old male patient with history of repaired hernia, who is admitted for 5 days of progressive dyspnea with diagnosis of abdominal sepsis, a computed tomography angiography was made, revealing pulmonary embolism in bilateral main pulmonary artery, and cardiac thrombectomy was performed.

Paciente masculino de 53 años de edad con historial de reparación de hernia, quien fue ingresado por presentar 5 días de disnea progresiva con diagnóstico de sepsis abdominal, se le realizó una angiografía por tomografía computada, revelando embolismo bilateral arteria pulmonar principal, se realizó una trombectomía cardíaca.

Outcomes with catheter-directed thrombolysis vs. catheter-directed embolectomy among patients with high-risk pulmonary embolism: a nationwide analysis.

AIMS: To examine the shot-term outcomes with catheter-directed thrombolysis (CDT) vs. catheter-directed embolectomy (CDE) for high-risk pulmonary embolism (PE). METHODS AND RESULTS: The Nationwide Readmissions Database was utilized to identify hospitalizations with high-risk PE undergoing CDE or CDT from 2016 to 2019. The main outcome was all-cause in-hospital mortality. Propensity score matching was used to compare the outcomes in both groups. Among 3216 high-risk PE hospitalizations undergoing catheter-directed interventions, 868 (27%) received CDE, 1864 (58%) received CDT, and 484 (15%) received both procedures. In the unadjusted analysis, the rate of all-cause in-hospital mortality was not different between CDE and CDT (39.6% vs. 34.2%, P = 0.07). After propensity score matching, there was no difference in the incidence of in-hospital mortality [adjusted odds ratio (aOR): 1.28, 95% confidence interval (CI): 0.95, 1.72, P = 0.10], intracranial haemorrhage (ICH) (adjusted OR 1.57, 95% CI: 0.75, 3.29, P = 0.23), or non-ICH bleeding (aOR: 1.17, 95% CI: 0.85, 1.62, P = 0.33). There were no differences in the length of stay, cost, and 30-day unplanned readmissions between both groups. CONCLUSION: In this contemporary observational analysis of patients admitted with high-risk PE undergoing CDT or CDE, the rates of in-hospital mortality, ICH, and non-ICH bleeding events were not different.

Comparison of the safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension patients with surgically accessible and inaccessible lesions.

BACKGROUND: Although pulmonary endarterectomy is the treatment of choice for chronic thromboembolic pulmonary hypertension, not all patients are eligible. While balloon pulmonary angioplasty is an alternative for such patients, its efficacy and safety may differ between patients with and without surgically accessible lesions. METHODS: This study involved 344 patients treated with balloon pulmonary angioplasty who were ineligible for pulmonary endarterectomy. Based on the angiographical lesion location, patients were divided into the surgically accessible (Group 1) and inaccessible (Group 2) groups, and percent changes in hemodynamics and clinical parameters before and after balloon pulmonary angioplasty were investigated. We also conducted survival analyses using Kaplan-Meier analysis. RESULTS: While no differences in baseline characteristics were identified between the groups, balloon pulmonary angioplasty significantly improved hemodynamics in both groups, without any difference regarding the incidence of complications. Meanwhile, the percent changes in the mean pulmonary arterial pressure, pulmonary vascular resistance, 6-min walk distance, right ventricular area index on echocardiography, and the achievement rate of World Health Organization functional class I after balloon pulmonary angioplasty were significantly lower in Group 1 than in Group 2. The cumulative survival rates at 1, 5, and 10 years after balloon pulmonary angioplasty were not significantly different between the two groups (Group 1: 92.5%, 86.1%, 84.3%; and Group 2: 96.5%, 92.9%, 90.1%, respectively). CONCLUSIONS: The outcome of balloon pulmonary angioplasty in inoperable patients with surgically accessible proximal lesions was acceptable; however, further investigations are necessary to clarify the optimal treatment for such patients.

Single-Cell Analysis Reveals Distinct Immune and Smooth Muscle Cell Populations that Contribute to Chronic Thromboembolic Pulmonary Hypertension.

Rationale: Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of acute pulmonary embolism (PE) in which the PE remodels into a chronic scar in the pulmonary arteries. This results in vascular obstruction, pulmonary microvasculopathy, and pulmonary hypertension. Objectives: Our current understanding of CTEPH pathobiology is primarily derived from cell-based studies limited by the use of specific cell markers or phenotypic modulation in cell culture. Therefore, our main objective was to identify the multiple cell types that constitute CTEPH thrombusy and to study their dysfunction. Methods: Here we used single-cell RNA sequencing of tissue removed at the time of pulmonary endarterectomy surgery from five patients to identify the multiple cell types. Using in vitro assays, we analyzed differences in phenotype between CTEPH thrombus and healthy pulmonary vascular cells. We studied potential therapeutic targets in cells isolated from CTEPH thrombus. Measurements and Main Results: Single-cell RNA sequencing identified multiple cell types, including macrophages, T cells, and smooth muscle cells (SMCs), that constitute CTEPH thrombus. Notably, multiple macrophage subclusters were identified but broadly split into two categories, with the larger group characterized by an upregulation of inflammatory signaling predicted to promote pulmonary vascular remodeling. CD4+ and CD8+ T cells were identified and likely contribute to chronic inflammation in CTEPH. SMCs were a heterogeneous population, with a cluster of myofibroblasts that express markers of fibrosis and are predicted to arise from other SMC clusters based on pseudotime analysis. Additionally, cultured endothelial, smooth muscle, and myofibroblast cells isolated from CTEPH fibrothrombotic material have distinct phenotypes from control cells with regard to angiogenic potential and rates of proliferation and apoptosis. Last, our analysis identified PAR1 (protease-activated receptor 1) as a potential therapeutic target that links thrombosis to chronic PE in CTEPH, with PAR1 inhibition decreasing SMC and myofibroblast proliferation and migration. Conclusions: These findings suggest a model for CTEPH similar to atherosclerosis, with chronic inflammation promoted by macrophages and T cells driving vascular remodeling through SMC modulation, and suggest new approaches for pharmacologically targeting this disease.

Clinical Outcomes of Endoscope-Assisted Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension.

PURPOSE: Pulmonary thromboembolism is a potentially life-threatening condition in patients with heart disease; however, limited studies discussing long-term outcomes exist. This study aimed to investigate the long-term outcomes of pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH), focusing on the improvement of functional class and right ventricular (RV) pressure. MATERIALS AND METHODS: Clinical data of patients with CTEPH were obtained from Yonsei Hospital between May 2012 and December 2021, and reviewed retrospectively. Twenty-six patients underwent endoscope-guided PEA during the study period, and the mean follow-up duration was 24.8±23.4 months. RESULTS: After PEA, most patients (88.5%) were weaned from inotropes without extracorporeal membrane oxygenation support during the first few days. Two patients (7.6%) had cerebrovascular accidents without neurological deficits. On echocardiography, the RV systolic pressure and tricuspid regurgitation grades significantly improved (p<0.001). Furthermore, the mean left ventricle end-diastolic diameter was significant increased (p=0.003), and the left ventricular end-systolic diameter increased (p<0.001). The median intensive care unit stay was 3.0±9.4 days, and median hospital stay 16.0±26.5 days. The 5-year survival rate was 95.5%, and the 5-year freedom rate of cardiac death was 100%. There was a marked improvement in New York Heart Association (NYHA) status (p<0.001). Cox regression suggested that the main pulmonary artery (MPA) involvement is a significant predictor of non-improvement in functional class post-PEA. CONCLUSION: Mortality rates are low and patients experience a marked improvement in NYHA class and health status after PEA. Moreover, MPA involvement may affect functional outcomes.