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Is it safe to thrombolyse patients with pulmonary embolism and right heart mobile thrombi?

Introduction

Right heart mobile thrombi (RHMT) are not frequent in patients with acute pulmonary embolism (APE); however, bear a significant risk of APE recurrence and hemodynamic compromise. Immediate therapy is recommended, but the optimal approach is considered to be controversial in the absence of controlled trials [1].

Methods

We report an analysis of 21 out of 209 (10%) consecutive patients with echocardiographically diagnosed RHMT managed at our institution during the past 5 years. For demographics, vital signs and laboratory values on entry see Table 1.

Table 1 (abstract P441)

Results

Eight (38%) out of 21 patients with RHMT presented with massive, 12 (57%) submassive and one with small APE. Right ventricle overload was detected in 20 out of 21 patients (95%). Fifteen (71%) patients were thrombolysed, three (14%) patients have undergone surgical embolectomy. Thrombolysis was successful in 13 out of 15 (87%) patients, RHMT was dislodged in two patients; in one of them with fatal outcome, the other one was urgently managed by venoarterial extracorporeal membrane oxygenation and subsequently by surgical embolectomy. The 30-day mortality was 10% (n = 2) in RHMT and 6% (n = 11 out of 188) in patients without RHMT.

Conclusion

Systemic thrombolysis is a safe and effective treatment for APE with RHMT. Urgent venoarterial extracorporeal membrane oxygenation as a rescue option for hemodynamic collapse in thrombus dislodgment opens a new therapeutic bridge to further decision and treatment.

References

  1. 1.

    Torbicki A, et al.: Guidelines on the diagnosis and management of acute pulmonary embolism: the Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC). Eur Heart J 2008, 29: 2276-2315. 10.1093/eurheartj/ehn475

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Belohlavek, J., Dytrych, V., Kral, A. et al. Is it safe to thrombolyse patients with pulmonary embolism and right heart mobile thrombi?. Crit Care 13, P441 (2009). https://doi.org/10.1186/cc7605

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Keywords

  • Public Health
  • Effective Treatment
  • Pulmonary Embolism
  • Emergency Medicine
  • Significant Risk