Stop That Clot
- 1. Stop That Clot! Management of Massive Pulmonary Embolism Mai Bui-Duy, MD
- 2. “Doc, I have…” Chest pain: central, “crushing,” pleuritic Shortness of breath Syncope
- 5. What Makes a “Massive” PE So Massive? http://www.hindawi.com/journals/crim/2010/862028/fig1/
- 6. What Makes a “Massive” PE So Massive?
- 7. Patients with PE & subsequent RV dysfunction can be roughly divided in 2 categories high-risk individuals w/ ‘massive’ PE with SBP</=90 or pressure drop of >40 mmHg x 15 min and lower-risk patients with ‘submassive’ PE, whose BP is preserved but whose RV function is impaired Massive PE is <5% of all PEs, but high mortality Management Strategies and Prognosis of Pulmonary Embolism Trial-3 (MAPPET-3): PE-related mortality in those with cardiac arrest: 60% PE-related mortality in those with cardiogenic shock: 23% PE-related mortality in those with arterial hypotension: 14%
- 8. Risk Stratification Studied in hemodynamically stable patients Meta-analysis: elevated BNP & pro-BNP had increased risk of adverse in-hospital outcome Meta-analysis: PE and elevated troponin had increase in: short-term risk of death by factor of 5.2 & increase in risk of death from PE by factor of 9.4 Klok et al. Am J Respir Crit Care Med 2008;178:425-30 Becattini et al. Circulation. 2007; 116: 427-433
- 9. Making The Diagnosis: CT Multidetector CT: used to diagnose or r/o PE Can also show RV size, which can be used for prognosis In one restrospective study, value <1.0 of RV/LV diameter had 100% negative predictive value for uneventful outcome Van der Meer Radiology. 2005 Jun;235(3):798-803
- 11. Making The Diagnosis: TTE Typical findings: RV hypokinesis, RV dilatation, intraventricular septal flattening w/ paradoxical motion toward LV, TR, pulmonary HTN, loss of inspiratory collapse of IVC
- 12. Making The Diagnosis: TTE McConnell’s sign: distinct regional pattern of right ventricular dysfunction, with akinesia of the mid free wall but normal motion at the apex 94% specificity for acute PE RV hypokinesis & dilatation found to be independent predictors of 30-day mortality (in hemodynamically stable) Ventricular septal bowing predictor of death related to PE McConnell et al. Am J Cardiol. 1996 Aug 15;78(4):469-73 Kucher et al. Arch Intern Med 2005;165:1777-81. Sanchez et al. Eur Heart J 2008:29:1569-77. Araoz et al. Radiology 2007;242:889-97.
- 13. Initial Supportive Treatment Provide oxygen & pain control Be judicious with IVF since volume overload can worsen RV failure; maintain CVP 15–20 cm H2O May need pressors: consider dopamine, Levophed or epinephrine for inotropic and vasopressor effects
- 14. Treatment: Medicine Heparin and/or systemic thrombolysis? 1st RCT: streptokinase+heparin vs heparin alone (n=8); survival greater in streptokinase arm 2hr infusion regimens of streptokinase (1.5 million units), urokinase and rt-PA (100 mg) followed by a heparin infusion have similar efficacy & safety Meta-analysis: in trials including massive PE & cardiac shock, thrombolysis a/w significant reduction in death and recurrent PE compared w/ heparin ICOPER: of those w/ masive PE (n=108): no difference in mortality or PE recurrence @ 90 days between thrombolysis vs heparin Wan et al. Circulation 2004;110, 744-749. Kucher et al. Circulation 2006;113, 577-582.
- 15. Treatment: Medicine Risk of bleeding! Contraindications: intracranial mass, h/o ICH, CVA or neurosurgical procedure within past 2 months, recent major trauma, severe uncontrolled HTN, ongoing suspicion for aortic dissection, active or recent respiratory/GI/GU bleeding… ICOPER: risk of ICH up to 3% Kucher et al. Circulation 2006;113, 577-582.
- 16. Treatment: IR Consider if contraindications against systemic thrombolysis or it has already failed Catheter-assisted embolectomy: low-dose ‘local’ fibrinolysis and thrombus fragmentation or aspiration Mechanical disruption of clot brings more surface area of clot in contact with thrombolytic agent Systematic review (15 trials, n=594): clinical success rate 86.5% w/ low rates of complications Kuo et al. J Vasc Interv Radiol 2009;20, 1431-1440.
- 17. Treatment: IR Grade 1 : fresh clot recently embolized, usually responds well to mechanical thrombectomy w/ increased flow & Oxygenation Grade 2 : older, more organized clot; more residual clot likely to remain but still good chance of significant improvement in pulmonary flow Grade 3 : old, organized chronic PE w/ recent worsening of acute-on-chronic PE; do not respond well to mechanical thrombectomy (need device that can scrape clot from vessel wall) Uflacker et al. J Vasc Interv Radiol 1996;7: 519-528. Lohan et al. Emerg Radiol 2007;13:161-169.
- 18. Treatment: Surgical Embolectomy Consider after failed fibrinolysis; effective with large centrally located thrombi Invasive: requires median sternotomy and cardiopulmonary bypass 1994 case series: surgical success 85% w/ 23% mortality vs medical therapy success rate of 75% & 33% mortality Gulba et al. Lancet 1994;343, 576-577.
- 19. Summary: Massive PE Suspected PE w/ cardiogenic shock and/or persistent arterial hypotension: weight-based UFH bolus first as continue workup If PE confirmed on imaging (CT/TTE), give thrombolytics If failed or contraindication to thrombolytics, consult IR/CT Surg for catheter-based thrombolysis or surgical embolectomy Konstantinides. N Engl J Med 2008;359:2804-13.
- 21. “Doc, I have renal failure!” If renal failure or contrast allergy, V/Q scans are alternative imaging mode Helpful if normal: negative predictive value of 97%
- 22. “Doc, I have renal failure!” If high-probability scan: positive predictive value of 85-90% Often inconclusive: diagnostic in only 30-50% of suspected PE http://www.acnmonline.org/index.cfm?PageID=9965
Editor's Notes
- #3: Doc, I have… symptoms and/or signs of PE
- #6: Definition of “massive” PE vs sub-massive (hemodynamic instability, not size of clot)
- #7: Definition of “massive” PE vs sub-massive (hemodynamic instability, not size of clot)
- #8: Management Strategies and Prognosis of Pulmonary Embolism Trial-3 (MAPPET-3) randomized 256 patients with submassive PE to receive recombinant tissue plasminogen activator (tPA) 100 mg over a 2-hour period followed by unfractionated heparin infusion or placebo plus heparin anticoagulation
- #9: Objectively adjudicated short-term adverse clinical events were used as a primary outcome of this meta-analysis. These included mortality or an adverse clinical outcome defined as the occurrence of any of the following: death, cardiopulmonary resuscitation, mechanical ventilation, use of vasopressors, thrombolysis, thrombosuction, open surgical embolectomy, or admission to the intensive care unit. Right ventricular dysfunction was used as secondary endpoint.
- #10: Diagnosis: imaging CT
- #11: Sometimes you can’t get to the CT scanner…
- #12: Or may see thrombus in RA or RV or PA directly!
- #14: Dobutamine will augment CO but may lead to arterial hypotension; may need to then support w/ phenylephrine which prevents tachycardia, which is good.
- #15: International Cooperative Pulmonary Embolism Registry UFH: 80 IU/kg of body wt as IV bolus followed by infusion of 18 units/kg/hr LMWH: Enox 1 mg/kg q12 or 1.5 mg/kg daily
- #16: International Cooperative Pulmonary Embolism Registry
- #17: Our definition of clinical success required stabilization of hemodynamics, resolution of hypoxia, and survival from massive PE, as reported in each study. Also, just because one dislodges the clot doesn’t mean that it goes away; likely will travel downstream and infarct smaller areas of lung Minor complications: No therapy, no consequence or Nominal therapy, no consequence; includes overnight admission for observation only Major complications: Require therapy, minor hospitalization (<48 h); Require major therapy, unplanned increase in level of care, prolonged hospitalization (>48 h); Permanent adverse sequelae; Death
- #18: Our definition of clinical success required stabilization of hemodynamics, resolution of hypoxia, and survival from massive PE, as reported in each study. Also, just because one dislodges the clot doesn’t mean that it goes away; likely will travel downstream and
- #19: We compared embolectomy (when available) with thrombolysis in patients with shock and massive pulmonary embolism. 13 patients were operated on, 10 (77%) of whom survived. The inferior vena cava was routinely clipped. The 24 medically treated patients were given alteplase until systemic and pulmonary artery pressures stabilised and heparin thereafter; 16 (67%) survived. Major haemorrhage occurred in 28% of medically treated patients, but was not fatal. 1 patient had a small cerebral haemorrhage that resolved without drainage. One-fifth of the medical group had a re-embolism, which suggests that temporary caval umbrellas are indicated in medically treated patients. Thrombolysis may provide a life-saving option and a randomised trial is warranted.
- #20: Therapy: medical: anti-coagulation w/ tPA
- #22: Diagnosis: V/Q scan
- #23: Diagnosis: V/Q scan