Medicine of the Future in America

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: Limitations

Management of Unsuccessful Thrombolysis in Acute Massive Pulmonary Embolism: LimitationsNonetheless, it must be noted that all patients who experienced major bleeding episodes in the repeat-thrombolysis group had a fatal outcome. This important result must be taken into account when evaluating the risk/benefit ratio and in the decision-making process. It underlines the clinical fragility of patients who are hemodynamically unstable, in whom the occurrence of a major bleeding complication is associated with an extremely unfavorable prognosis.
A “watchful waiting” approach after initial thrombolysis in patients who have experienced a massive PE is probably most appropriate. The persistence of echocardiographic signs of RV dysfunction combined with poor clinical tolerance call for a repeat-reperfusion strategy, preferably using surgical embo-lectomy, based on our experience. In most clinical settings, the readministration of a thrombolytic agent is the only form of treatment available for PE patients who are unresponsive to the initial thrombolysis. In this context, the transfer of these patients to tertiary cardiac surgery centers could be considered as an alternative option.
The treatment assignment, after the patient has not responded to thrombolysis, to either the readministration of a thrombolytic agent or to rescue surgical embolectomy, was not randomized. There could have been several potential selection biases. As the management strategy of patients was left entirely to the discretion of the attending physician, it is quite possible that older age and the presence of right heart thrombi led to a decision in favor of surgical therapy rather than for repeat thrombolysis. There were no significant differences between treatment groups in terms of clinical presentation, echocardio-graphic findings, and the location of pulmonary emboli, before and after thrombolytic therapy, except with regard to intracardiac thrombus. However, it should be noted that there were nearly twice as many patients in the repeat-thrombolysis group. Despite the fact that this study was conducted over a long period of time, the thrombolytic agents and surgical embolectomy techniques used remained unchanged throughout the whole study period.

This entry was posted in Pulmonary function and tagged embolism, surgery, thrombolysis.
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