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Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: Clinical Presentation on Hospital Admission

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: Clinical Presentation on Hospital AdmissionThe clinical characteristics of patients at hospital admission are reported in Table 1. The study population was made up of 15 men (38%) and 25 women (62%), with a mean age of 62 ± 18 years (age range, 26 to 84 years). Fourteen patients underwent rescue embolectomy, and 26 underwent repeat thrombolysis. There were no significant differences between the two treatment groups in terms of baseline demographic and clinical characteristics. PE was initially diagnosed by pulmonary angiogram in 12 patients (30%), by high-probability lung scan in 7 patients (17%), and by spiral CT scan in 21 patients (53%). The onset of symptoms dated from < 6 days in about 60% of patients, with no significant difference between the two groups. http://birthcontroltab.com/

All of the study patients were initially in severe clinical condition, and presented with cardiogenic shock, systemic arterial hypotension, syncope, or tachycardia. All patients from the rescue embolec-tomy group had either refractory cardiogenic shock (five patients) or systemic hypotension (nine patients) following the initial thrombolysis. In the repeat-thrombolysis group, 21 patients presented with either cardiogenic shock (4 patients) or systemic hypotension (17 patients), while the remaining 5 patients had severe sustained tachycardia or severe hypoxemia. Severe hypoxemia was observed in 35 patients (88%) [Table 2].
The initial transthoracic echocardiographic examination revealed the presence of RV dysfunction in 86% of surgically treated patients and in 88% of medically treated patients. RV dilatation was the most common sign of RV overload. The mean tricuspid regurgitant jet velocity was 3.6 ± 1.2 m/s in the surgical group compared with 3.4 ± 1.3 m/s in the repeat-thrombolysis group, corresponding to mean systolic pressures of 56 ± 11 and 51 ± 7 mm Hg, respectively. The presence of right heart thrombus was significantly more frequently observed in patients who had undergone surgical embolectomy when compared to those who had undergone repeat thrombolysis (3 patients [21%] vs 0, respectively; p = 0.01).

Table 1—Patient Characteristics at Diagnosis

Characteristics Rescue Embolectomy (n = 14) RepeatThrombolysis

(n = 26)

p Value
Sex 0.23
Female 7 8
Male 7 18
Age, yr 67.6 ± 14.3 62.9 ± 16.9 0.10
History of thromboembolic 2 (14) 5 (19) 0.69
disease
Cardiopulmonary disease 1(7) 0 0.17
Cancer 4(29) 4(15) 0.32
Onset of symptoms
< 6 d 9(64) 16 (62) 0.86
< 14 d and > 6 d 5 (36) 10 (38)
Syncope 6 (43) 7(27) 0.31
Pao2, mm Hg 55.9 ± 6.7 58.2 ± 7.5 0.15
ECG with RV overload 10(71) 16 (62) 0.53
Thrombolytic agent 0.91
Streptokinase 10 19
t-PA 4 7
DVT 8(57) 17 (65) 0.61

Table 2—Prethrombolysis and Postthrombolysis Data

Variables Prethrombolysis Data Postthrombolysis Data
iRescue Embolectomy (n = 14) RepeatThrombolysis

(n = 26)

p Value Rescue Embolectomy (n = 14) RepeatThrombolysis

(n = 26)

p Value
Clinical findings
Shock 5 (36) 4(15) 0.14 5 (36) 4(15) 0.07
Systemic hypotension 9 (64) 17 (65) 0.95 9 (64) 17 (65) 0.95
PaO£ ^ 55 mm Hg or pulse oximetry < 90% 12 (86) 21 (81) 0.70 13 (93) 23 (88) 0.66
Heart rate > 110 beats/min 12 (86) 23 (88) 0.80 13 (93) 25 (96) 0.65
More than one of the above 14 (100) 26 (100) 14 (100) 26(100)
Echocardiographic findings
RVEDD/LVEDD ratio > 1 12 (86) 23 (88) 0.80 13 (93) 23 (88) 0.66
Paradoxical septal systolic motion 8 (57) 14 (54) 0.84 8(57) 15 (58) 0.97
sPAP > 30 mm Hg 11 (79) 17 (65) 0.39 11 (79) 18 (69) 0.53
Intracardiac thrombus 3 (21) 0 0.01 2 (21) 0 0.05
More than one of the above 13 (93) 24 (92) 0.95 14 (100) 26(100)
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