Sustained improvement of pulmonary hemodynamics in patients at rest and during exercise after thrombolytic treatment of massive pulmonary embolism.

Abstract

This study assessed the long-term effects of thrombolytic treatment in patients with acute massive pulmonary embolism (PE). Seven patients with PE that followed deep-vein thrombosis underwent pulmonary angiography and pressure measurements before and 6 ± 3 days (mean ± SD) and 15 ± 4 months after treatment with intrapulmonary infusions of urokinase (average dose 1724 U/ kg.hr) and heparin (average dose 17 U/kg.hr). Treatment was guided by daily measurements of pulmonary arterial (PA) pressure and was continued until PA pressure had normalized (average of 6 days). Late after treatment patients retumed for pulmonary angiographic examination, right heart catheterization at rest and during bicycle exercise, and phlebography of the deep veins of both legs. Pulmonary angiograms showed massive obstruction before therapy (Walsh index 15 2 points of a maximum of 18 points), which was improved 6 days (3 ± 3 points) and 15 months (1 2 points) after therapy. Mean PA pressure declined from 37 ± 9 to 13 ± 3 mm Hg after 6 days and to 15 + 3 mm Hg after 15 months. No recurrence of PE was observed. In six of seven patients at rest and during bicycle exercise (up to 100 W) in the supine position mean PA pressure and total pulmonary resistance remained within normal limits. Over the short term all patients showed clinical signs of deep-vein thrombosis; 15 months later four patients had normal deep veins, but three patients had still phlebographic signs of old thrombosis. Thus, after thrombolytic treatment of acute massive PE normal pulmonary arteriograms were obtained in six of seven patients studied; furthermore, the reserve capacity of the pulmonary vasculature as assessed during heavy exercise was normal in these patients. Circulation 71, No. 1, 117-123, 1985. WHEREAS the short-term effects of thrombolytic treatment in patients with pulmonary embolism (PE) are well known, 14 only a few long-term hemodynamic studies have been conducted.5' 6 Cases of chronic cor pulmonale resulting from unresolved PE have been reported, but the incidence of chronic pulmonary hypertension is not completely known." The factors that determine whether a patient will have complete resolution of a clot or whether unresolved emboli will persist have not been clearly delineated.9Thrombolytic drugs induce rapid lysis of angiographically visible clots in the pulmonary vasculature

Long-term benefit of thrombolytic therapy in patients with pulmonary embolism

“…15 In a long-term follow-up study carried out 4 years after the initial embolic episode, DeSoyza and Murphy 16 reported high resting PA pressures with an abnormal elevation on exercise in 9 (69%) of 13 patients. In contrast with the persistent post-embolic pul-Vascular Medicine 2000; 5: 91-95 monary hypertension in the above studies, Schwarz et al 17 reported sustained improvement of pulmonary hemodynamics both at rest and during exercise in six (85%) of the seven patients who were treated with urokinase for massive PE and studied 15 months later.…”

Systemic Thrombolysis, Catheter‐Directed Thrombolysis, and Anticoagulation for Intermediate‐risk Pulmonary Embolism: A Simulation Modeling Analysis

“…There is some evidence that thrombolysis results in favorable quality‐of‐life outcomes, when compared with anticoagulation alone . However, recent studies have failed to show a definite effect of thrombolysis on right ventricular function and functional outcomes .…”

Pulmonary Embolism Response Teams

“…Guidelines recommend systemic IV thrombolysis for patients with high-risk PE and no contraindications, as thrombolysis has been associated with improvement in hemodynamics and right ventricular function. 3,15,[28][29][30][31] The role of systemic thrombolysis in intermediate-risk PE, however, remains controversial. Two recent randomized, placebo-controlled clinical trials, the Tenecteplase Or Placebo in the Care Of Acute Thromboembolism (TOPCOAT) and the Pulmonary Embolism Thrombolysis (PEITHO) studies, evaluated the role of systemic thrombolysis in intermediate-risk PE.…”