Acoustic Pulse Thrombolytic Therapy for Acute Submassive Pulmonary Embolism Decreases the Risk of Developing Chronic Thromboembolic Pulmonary Hypertension
Nicolas J. Mouawad, MD MPH MBA RPVI1, Jenna Lee2, Matthew Lee2, Kalie Taylor, RN2, Kalil Masri, MD1.
1McLaren Bay Region / Michigan State University, Bay City, MI, USA, 2McLaren Bay Region, Bay City, MI, USA.
Chronic thromboembolic pulmonary hypertension (CTEPH) is a disabling condition affecting .04%-9.1% of patients who suffer with an initial episode of pulmonary embolism and is estimated at 3.8% two years following initial insult. Conventional treatment involves systemic anticoagulation with intravenous heparin and ultimately conversion to oral anticoagulants. As part of our aggressive and progressive multi-disciplinary Pulmonary Embolism Response Team (PERT), we hypothesized that patients undergoing aggressive therapy with catheter-directed, ultrasound-assisted thrombolysis (CDUAT), will have a decreased incidence of CTEPH at 2 years follow-up.
A retrospective analysis of prospectively collected data was performed at our institution for all patients presenting with submassive pulmonary emboli as defined by our PERT criteria. All patients underwent catheter-directed, ultrasound-assisted thrombolysis. Data collected included patient demographics, comorbidities, previous episodes of venous thromboembolism, presenting vital signs, laboratory and cardiac biomarkers for ventricular strain, and time until initiation of thrombolysis. Independent review of echocardiographic findings for right ventricular strain as well as computed tomography angiography imaging was conducted for RV:LV ratio and thrombus burden at presentation and at 2 years follow up.
A total of 31 patients presented to our PERT protocol with submassive pulmonary embolism over a 3 year period. The average age was 55 (26-85 years) and 55% were male. 12.9% had negative cardiac biomarkers. The pre-CDUAT RV pressure is 52.99mmHg (16.4-99.6). Saddle PE was identified in 45%. At 28 months follow up, nine patients have been reviewed with a mean RV pressure 34.2mmHg (30.3-42.3) with negative biomarkers and no clinical signs of pulmonary hypertension or CTEPH.
Chronic thromboembolic pulmonary hypertension occurs when a pulmonary embolism fails to undergo complete thrombolysis leading to vascular occlusion and pulmonary hypertension. Aggressive intervention using catheter-directed, ultrasound-guided pulmonary thrombolysis in patients presenting with submassive PE demonstrates promising results in decreasing the incidence of long-term sequelae of CTEPH. Further studies with longer follow-up are necessary to support these initial findings.
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