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Thrombolytic therapy during resuscitation for pulmonary embolism-related out-of-hospital cardiac arrest: perhaps not the ideal solution for everyone
Critical Care volume 24, Article number: 64 (2020)
Javaudin et al.  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) . 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 . However, further research is required to determine the optimal application of this technique in the setting of acute PE . 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 . According to a recent systematic review, VA-ECMO for selected patients with massive PE is associated with good outcome .
Third, after failure of thrombolysis, surgical embolectomy or catheter embolectomy should be considered in selected centers . Fourth, published cases of thrombolysis for massive PE during pregnancy and the postpartum period suggest acceptable maternal and fetal survival even with CA . 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 . 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 . 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 . 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 . 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
Out-of-hospital cardiac arrest
Veno-arterial extracorporeal membrane oxygenation
Chronic thromboembolic pulmonary hypertension
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We would like to thank Dr. Melissa Jackson for critical review of the manuscript.
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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