In addition, the bleeding rate observed in the repeat-thrombolysis group may have been underestimated, since thrombolytic therapy is usually not readministered to patients who experience a bleeding complication after receiving the first thrombolytic dose. Hence, selection bias may have caused less bleeding in the patients who underwent repeat thrombolysis. read more
Furthermore, the extrapolation of our results to other centers can be envisaged only if an experienced surgical team similar to ours is available, since few centers have surgeons who are experienced in performing pulmonary embolectomy. Similarly, it should be noted that most of the patients who underwent thrombolysis (73%) were initially treated with streptokinase. Therefore, some caution should be exercised in the extrapolation of these results to other groups of patients undergoing thrombolysis. Despite these limitations, a more aggressive approach toward patients presenting after not responding to thrombolysis is associated with improved prognosis.
Lack of response to thrombolysis, which was defined as persistent RV dysfunction and hemodynamic instability, can be expected in about 8% of patients who experience massive PE. Rescue surgical embolectomy led to a better in-hospital course when compared with repeat thrombolysis in such patients. An uneventful in-hospital evolution was significantly higher in the surgical group, due to a lower inhospital mortality rate, less frequent episodes of major bleeding, and recurrent PE. Based on our results, and pending confirmation in a randomized trial, repeat thrombolysis is not to be recommended in this setting. The transfer of patients who have not responded to thrombolysis to tertiary cardiac surgery centers could be considered as an option in this context.