Mechanical thrombectomy in intermediate- and high-risk acute pulmonary embolism: hemodynamic outcomes at three months.
Mechanical thrombectomy
Pulmonary embolism
Journal
Respiratory research
ISSN: 1465-993X
Titre abrégé: Respir Res
Pays: England
ID NLM: 101090633
Informations de publication
Date de publication:
25 Oct 2023
25 Oct 2023
Historique:
received:
09
06
2023
accepted:
03
10
2023
medline:
27
10
2023
pubmed:
26
10
2023
entrez:
25
10
2023
Statut:
epublish
Résumé
Mechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload. In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up. Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events. Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.
Sections du résumé
BACKGROUND
BACKGROUND
Mechanical thrombectomy has been shown to reduce thrombus burden and pulmonary artery pressure (PAP) and to improve right ventricular (RV) function in patients with high-risk or intermediate-high-risk pulmonary embolism (PE). As hemodynamic data after mechanical thrombectomy for PE are scarce, we aimed to assess the hemodynamic effects of mechanical thrombectomy in acute PE with right heart overload.
METHODS
METHODS
In this prospective, open-label study, patients with acute symptomatic, computed tomography-documented PE with signs of right heart overload underwent mechanical thrombectomy using the FlowTriever System. Right heart catheterization was performed immediately before and after thrombectomy and after three months. Transthoracic echocardiography was performed before thrombectomy, discharge, and at three months. This analysis was done after 20 patients completed three months of follow-up.
RESULTS
RESULTS
Twenty-nine patients (34% female) underwent mechanical thrombectomy, of which 20 completed three months follow-up with right heart catheterization. Most patients were at high (17%) or intermediate-high (76%) risk and had bilateral PE (79%). Before thrombectomy, systolic PAP (sPAP) was severely elevated (mean 51.3 ± 11.6 mmHg). Mean sPAP dropped by -15.0 mmHg (95% confidence interval [CI]: -18.9 to -11.0; p < 0.001) immediately after the procedure and continued to decrease from post-thrombectomy to three months (-6.4 mmHg, 95% CI: -10-0 to -2.9; p = 0.002). RV/left ventricular (LV) ratio immediately reduced within two days by -0.37 (95% CI: -0.47 to -0.27; p < 0.001). The proportion of patients with a tricuspid annular plane systolic excursion (TAPSE)/sPAP ratio < 0.31 mm/mmHg decreased from 28% at baseline to 0% before discharge and at three months (p = 0.007). There were no procedure-related major adverse events.
CONCLUSIONS
CONCLUSIONS
Mechanical thrombectomy for acute PE was safe and immediately reduced PAP and improved right heart function. The reduction in PAP was maintained at three months follow-up.
Identifiants
pubmed: 37880651
doi: 10.1186/s12931-023-02552-w
pii: 10.1186/s12931-023-02552-w
pmc: PMC10601326
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
257Informations de copyright
© 2023. BioMed Central Ltd., part of Springer Nature.
Références
Jimenez D, de Miguel-Diez J, Guijarro R, Trujillo-Santos J, Otero R, Barba R, et al. Trends in the management and outcomes of Acute Pulmonary Embolism: analysis from the RIETE Registry. J Am Coll Cardiol. 2016;67(2):162–70.
doi: 10.1016/j.jacc.2015.10.060
pubmed: 26791063
Jimenez D, Bikdeli B, Barrios D, Quezada A, Del Toro J, Vidal G, et al. Epidemiology, patterns of care and mortality for patients with hemodynamically unstable acute symptomatic pulmonary embolism. Int J Cardiol. 2018;269:327–33.
doi: 10.1016/j.ijcard.2018.07.059
pubmed: 30025658
Konstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the european respiratory society (ERS). Eur Heart J. 2020;41(4):543–603.
doi: 10.1093/eurheartj/ehz405
pubmed: 31504429
Marti C, John G, Konstantinides S, Combescure C, Sanchez O, Lankeit M, et al. Systemic thrombolytic therapy for acute pulmonary embolism: a systematic review and meta-analysis. Eur Heart J. 2015;36(10):605–14.
doi: 10.1093/eurheartj/ehu218
pubmed: 24917641
Konstantinides SV, Barco S. Systemic thrombolytic therapy for Acute Pulmonary Embolism: who is a candidate? Semin Respir Crit Care Med. 2017;38(1):56–65.
doi: 10.1055/s-0036-1597560
pubmed: 28208199
Keller K, Hobohm L, Ebner M, Kresoja KP, Munzel T, Konstantinides SV, et al. Trends in thrombolytic treatment and outcomes of acute pulmonary embolism in Germany. Eur Heart J. 2020;41(4):522–9.
doi: 10.1093/eurheartj/ehz236
pubmed: 31102407
Gotzinger F, Lauder L, Sharp ASP, Lang IM, Rosenkranz S, Konstantinides S et al. Interventional therapies for pulmonary embolism. Nat Rev Cardiol. 2023:1–15.
Giri J, Sista AK, Weinberg I, Kearon C, Kumbhani DJ, Desai ND, et al. Interventional therapies for Acute Pulmonary Embolism: current status and principles for the development of Novel evidence: a Scientific Statement from the American Heart Association. Circulation. 2019;140(20):e774–e801.
doi: 10.1161/CIR.0000000000000707
pubmed: 31585051
Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, et al. Executive Summary: antithrombotic therapy for VTE Disease: second update of the CHEST Guideline and Expert Panel Report. Chest. 2021;160(6):2247–59.
doi: 10.1016/j.chest.2021.07.056
pubmed: 34352279
Pruszczyk P, Klok FA, Kucher N, Roik M, Meneveau N, Sharp ASP, et al. Percutaneous treatment options for acute pulmonary embolism: a clinical consensus statement by the ESC Working Group on Pulmonary circulation and right ventricular function and the European Association of Percutaneous Cardiovascular Interventions. EuroIntervention. 2022;18(8):e623–e38.
doi: 10.4244/EIJ-D-22-00246
pubmed: 36112184
pmcid: 10241264
Tu T, Toma C, Tapson VF, Adams C, Jaber WA, Silver M, et al. A prospective, Single-Arm, Multicenter Trial of Catheter-Directed Mechanical Thrombectomy for Intermediate-Risk Acute Pulmonary Embolism: the FLARE Study. JACC Cardiovasc Interv. 2019;12(9):859–69.
doi: 10.1016/j.jcin.2018.12.022
pubmed: 31072507
Toma C, Jaber WA, Weinberg MD, Bunte MC, Khandhar S, Stegman B et al. Acute outcomes for the full US cohort of the FLASH mechanical thrombectomy registry in pulmonary embolism. EuroIntervention. 2022.
Aujesky D, Obrosky DS, Stone RA, Auble TE, Perrier A, Cornuz J, et al. Derivation and validation of a prognostic model for pulmonary embolism. Am J Respir Crit Care Med. 2005;172(8):1041–6.
doi: 10.1164/rccm.200506-862OC
pubmed: 16020800
pmcid: 2718410
Tello K, Wan J, Dalmer A, Vanderpool R, Ghofrani HA, Naeije R, et al. Validation of the tricuspid annular plane systolic Excursion/Systolic pulmonary artery pressure ratio for the Assessment of right ventricular-arterial coupling in severe pulmonary hypertension. Circ Cardiovasc Imaging. 2019;12(9):e009047.
doi: 10.1161/CIRCIMAGING.119.009047
pubmed: 31500448
pmcid: 7099862
Hareendran A, Leidy NK, Monz BU, Winnette R, Becker K, Mahler DA. Proposing a standardized method for evaluating patient report of the intensity of dyspnea during exercise testing in COPD. Int J Chron Obstruct Pulmon Dis. 2012;7:345–55.
doi: 10.2147/COPD.S29571
pubmed: 22745534
pmcid: 3379870
Klok FA, Ageno W, Ay C, Back M, Barco S, Bertoletti L, et al. Optimal follow-up after acute pulmonary embolism: a position paper of the European Society of Cardiology Working Group on Pulmonary circulation and right ventricular function, in collaboration with the European Society of Cardiology Working Group on Atherosclerosis and Vascular Biology, endorsed by the european respiratory society. Eur Heart J. 2022;43(3):183–9.
doi: 10.1093/eurheartj/ehab816
pubmed: 34875048
Cooper R, Ghali J, Simmons BE, Castaner A. Elevated pulmonary artery pressure. An independent predictor of mortality. Chest. 1991;99(1):112–20.
doi: 10.1378/chest.99.1.112
pubmed: 1824624
Heresi GA, Minai OA, Tonelli AR, Hammel JP, Farha S, Parambil JG, et al. Clinical characterization and survival of patients with borderline elevation in pulmonary artery pressure. Pulm Circ. 2013;3(4):916–25.
doi: 10.1086/674756
pubmed: 25006408
pmcid: 4070822
Douschan P, Kovacs G, Avian A, Foris V, Gruber F, Olschewski A, et al. Mild elevation of pulmonary arterial pressure as a predictor of Mortality. Am J Respir Crit Care Med. 2018;197(4):509–16.
doi: 10.1164/rccm.201706-1215OC
pubmed: 29099619
Maron BA, Hess E, Maddox TM, Opotowsky AR, Tedford RJ, Lahm T, et al. Association of Borderline Pulmonary Hypertension with Mortality and hospitalization in a large patient cohort: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program. Circulation. 2016;133(13):1240–8.
doi: 10.1161/CIRCULATIONAHA.115.020207
pubmed: 26873944
pmcid: 4811678
Fauvel C, Raitiere O, Boucly A, De Groote P, Renard S, Bertona J, et al. Interest of TAPSE/sPAP ratio for noninvasive pulmonary arterial hypertension risk assessment. J Heart Lung Transplant. 2022;41(12):1761–72.
doi: 10.1016/j.healun.2022.09.005
pubmed: 36202691
Tello K, Axmann J, Ghofrani HA, Naeije R, Narcin N, Rieth A, et al. Relevance of the TAPSE/PASP ratio in pulmonary arterial hypertension. Int J Cardiol. 2018;266:229–35.
doi: 10.1016/j.ijcard.2018.01.053
pubmed: 29887454
Ismayl M, Machanahalli Balakrishna A, Aboeata A, Gupta T, Young MN, Altin SE, et al. Meta-analysis comparing Catheter-Directed Thrombolysis Versus systemic anticoagulation alone for Submassive Pulmonary Embolism. Am J Cardiol. 2022;178:154–62.
doi: 10.1016/j.amjcard.2022.06.004
pubmed: 35778309
Buckley JR, Wible BC. In-Hospital mortality and related outcomes for elevated risk Acute Pulmonary Embolism treated with mechanical Thrombectomy Versus Routine Care. J Intensive Care Med. 2022;37(7):877–82.
doi: 10.1177/08850666211036446
pubmed: 34397286