Skip to main content

Thrombolytic therapy during resuscitation for pulmonary embolism-related out-of-hospital cardiac arrest: perhaps not the ideal solution for everyone

The Original Article was published on 13 December 2019

Javaudin et al. [1] recommended that for cases of out-of-hospital cardiac arrest (OHCA) for which a cause is not obvious, pulmonary embolism (PE) should be suspected if the initial rhythm is nonshockable and there is a history of thromboembolism (TE). In accordance with the guidelines of the American Heart Association, these patients could be treated with systemic thrombolysis (ST) during resuscitation (low level of evidence) [1]. We would like to add some comments. First, recent studies have shown that ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial hemorrhage than historical rates with ST [2]. However, further research is required to determine the optimal application of this technique in the setting of acute PE [2]. Second, the insertion of an emergency veno-arterial extracorporeal membrane oxygenation (VA-ECMO) catheter should be considered before starting ST. VA-ECMO can be a lifesaving therapeutic consideration, either as an adjunct to definitive management strategies (surgical/catheter embolectomy, thrombolysis) or on its own [3]. According to a recent systematic review, VA-ECMO for selected patients with massive PE is associated with good outcome [3].

Third, after failure of thrombolysis, surgical embolectomy or catheter embolectomy should be considered in selected centers [3]. Fourth, published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest acceptable maternal and fetal survival even with CA [4]. In the postpartum period, given the high risk of major bleeding with thrombolysis, other therapeutic options (catheter or surgical thrombectomy, VA-ECMO) should be considered if available [4]. Lastly, chronic thromboembolic pulmonary hypertension (CTEPH) is a pulmonary vascular disease caused by chronic obstruction of major pulmonary arteries and often occurs after an initial PE or TE [5]. The authors note the importance of a past history of PE or TE as a risk factor and should therefore consider CTEPH as well. CTEPH can be cured by pulmonary endarterectomy (PEA), a challenging procedure for which patient selection and perioperative management are complex, requiring significant experience [5]. We had a 45-year-old patient with CTEPH who, after failed thrombolysis, was transferred to another center for PEA and achieved a full recovery [5]. Thrombolysis may not be the cure for everyone. A clear step by step approach should be considered in case of failed thrombolysis.

Availability of data and materials

Not applicable.

Abbreviations

OHCA:

Out-of-hospital cardiac arrest

PE:

Pulmonary embolism

CA:

Cardiac arrest

TE:

Thromboembolism

ST:

Systemic thrombolysis

VA-ECMO:

Veno-arterial extracorporeal membrane oxygenation

CTEPH:

Chronic thromboembolic pulmonary hypertension

PEA:

Pulmonary endarterectomy

References

  1. Javaudin F, Lascarrou JB, Esquina H, Baert V, Hubert H, Leclère B, GR-RéAC. Improving identification of pulmonary embolism-related out-of-hospital cardiac arrest to optimize thrombolytic therapy during resuscitation. Crit Care. 2019;23(1):409. https://doi.org/10.1186/s13054-019-2672-6 No abstract available.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chopard R, Ecarnot F, Meneveau N. Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence. Eur Heart J Suppl. 2019;21(Suppl I):I23–30. https://doi.org/10.1093/eurheartj/suz224 Epub 2019 Nov 21.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Yusuff HO, Zochios V, Vuylsteke A. Extracorporeal membrane oxygenation in acute massive pulmonary embolism: a systematic review. Perfusion. 2015;30(8):611–6. https://doi.org/10.1177/0267659115583377 Epub 2015 Apr 24.

    Article  CAS  PubMed  Google Scholar 

  4. Martillotti G, Boehlen F, Robert-Ebadi H, Jastrow N, Righini M, Blondon M. Treatment options for severe pulmonary embolism during pregnancy and the postpartum period: a systematic review. J Thromb Haemost 2017;15(10):1942–1950. doi: https://doi.org/10.1111/jth.13802. Epub 2017 Sep 12.

    Article  CAS  Google Scholar 

  5. Segel MJ, Kogan A, Preissman S, Agmon-Levin N, Lubetsky A, Fefer P, Schaefers H, Raanani E. Pulmonary endarterectomy surgery for chronic thromboembolic pulmonary hypertension: a small-volume national referral center experience.Isr Med Assoc J. <https://www.ncbi.nlm.nih.gov/pubmed/?term=Segel+MJ%2C+Kogan+A%2C+Preissman+S%2C#> 2019;21(8):528–531.

Download references

Acknowledgements

We would like to thank Dr. Melissa Jackson for critical review of the manuscript.

Funding

None.

Author information

Authors and Affiliations

Authors

Contributions

PMH, SR, and DDB designed the paper. All authors participated in drafting the manuscript. All authors have read and approved the final version.

Corresponding author

Correspondence to Patrick M. Honore.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This comment refers to the article available at https://doi.org/10.1186/s13054-019-2672-6

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Honore, P.M., David, C., Mugisha, A. et al. Thrombolytic therapy during resuscitation for pulmonary embolism-related out-of-hospital cardiac arrest: perhaps not the ideal solution for everyone. Crit Care 24, 64 (2020). https://doi.org/10.1186/s13054-020-2803-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13054-020-2803-0