PULMONARY THROMBECTOMY WITH CATHETER FOR THE TREATMENT OF ACUTE PULMONARY EMBOLISM: A LOCAL PROTOCOL

In February 2021, a PDTA on Pulmonary Embolism (PE) was approved in our hospital, including a chapter describing a protocol for the treatment with catheter thrombectomy (CT) of patients with high and intermediate risk PE. The protocol took into account the recommendations of the ESC 2019 guidelines on PE, and was produced to describe a path to improve the treatment of patients with PE It included: a) thrombectomy with aspiration in patients high-risk patients, with no haemodynamic improvement after administration of systemic thrombolytic therapy (TT) or with absolute contraindication to it;b) thrombectomy with loco-regional ultrasound-assisted thrombolysis (USAT) in patients at high-intermediate risk. 20 patients were treated from February 2020 to September 2021. 55% were men, with an average age of 73 ± 13 years;all patients met the criteria for inclusion in the protocol and signed a consensus document. 2 high-risk patients were treated with thromboaspiration: one patient for absolute contraindication to TT (recent spontaneous brain haemorrhage), the other one for a syncopal episode with head trauma. 18 patients (92%) at high intermediate risk were treated with USAT. For the 90% of patients were used 2 catheters;in 72% the administered dose of rt-PA was 24 mg. The mean value of NT- proBNP was 2,896 ng/l (normal m<93, f<144) There was only one major bleeding complication in the high-intermediate risk group (macrohematuria) during hospitalization. The mean RV/LV ratio was 1.48 (± 0.14) at baseline and 0.85 (± 0.14) at 48 hours with a reduction of 43%. The 2 high-risk patients died: one 1 month after the procedure, due to the effects of cerebral haemorrhage, the other one after 10 days due to respiratory complications. The mean FU of 17 patients was 228 days (± 193);during the FU there was a recurrence of PE (6%) after the discontinuation of anticoagulant therapy;there were no haemorrhages. RV dysfunction persisted in one patient (6%) with CTEPH who subsequently underwent pulmonary endarterectomy. Conclusion: PDTA and teamwork helped to improve the therapeutic decision making in patients with PE at a high and intermediate-high risk, despite the difficulties due to the SARS-COV-2 pandemic. Our experience was found to be in line with what has been published on the efficacy and safety of CT. (Figure Presented).

Platypnea-orthodeoxia syndrome years after acute pulmonary embolism: Two consecutive cases

Platypnea-Orthodeoxia syndrome (POS) is a rare condition in which dyspnoea and arterial oxygen desaturation are present in the upright position, while in the supine position, they are alleviated. It is observed in the presence of an anatomical (intra-or extracardiac) communication between the right and left heart causing a right-to-left shunt. POS is most frequently caused by a patent foramen ovale (PFO) and usually, the clinical assessment and a transthoracic echocardiograms with bubble study are enough to reach the diagnosis. The only possible treatment of POS is the percutaneous closure of the defect. We describe two cases of POS due to a PFO which manifested itself years after an episode of acute pulmonary embolism (PE), a finding never reported to date in the literature. Few cases describe the relationship between PE and POS, but these conditions may be more closely related than we currently think.

A rare case of biventricular thrombosis

In March 2020, a 53-year-old woman with cardiovascular risk factors (obesity and arterial hypertension) came to the emergency room for worsening exertional dyspnoea and swollen legs for a month. She experienced an episode of right popliteal DVT during chemotherapy for a non-Hodgkin's lymphoma and cardiomyopathy after the chemotherapy (LVEF 45%). The EKG showed a 2:1 atrial flutter with a HR of 120 bpm. The echocardiogram showed: a dilated RV with reduced systolic function (TAPSE 12 mm), a floating thrombus in the right atrium and 2 fixed thrombi in the RV (on the moderator band and the septal cusp of the tricuspid valve), a dilated LV with widespread hypokinesia and EF 20%, a voluminous pedunculated apical thrombus. A CT pulmonary angiogram showed: bilateral thrombosis of segmental and subsegmental branches, an RV/LV ratio >1, a voluminous thrombus in the apex of the LV and 2 thrombi in the RV, total thrombotic occlusion of the right superior vena cava. A venous doppler ultrasound showed thrombosis of the right popliteal vein. She was admitted to CCU and treated with furosemide, antialdosteronic agent, ACE-inhibitor, beta-blocker, digitalis, unfractionated heparin (subsequently replaced with warfarin after 2 days of INR >2). Then, he underwent: a cardiac MRI confirming the LV and RV thrombi and the depressed biventricular EF, a total body CT excluding a lymphoma's recurrence and a coronary CT angiography which did not detect coronary stenosis. Two nasal swabs were negative for SARS-Cov-2 infection. After 24 hours, the sinus rhythm spontaneously restored. After 15 days of anticoagulant therapy, the endocavitary thrombi dissolved. She was discharged after 30 days of hospitalization in stable conditions, but with the persistence of biventricular dysfunction on the echocardiogram. On the 3-month FU, the patient was in stable conditions (NYHA II);the echocardiogram showed normalization of the RV function and improvement of the LV one (EF 45%). Conclusion: This is a rare case of biventricular thrombosis with no guidelines for its treatment in the literature. The common practice consists in heparin anticoagulant therapy followed by a vitamin-K antagonist. This therapeutic regimen allowed, in this specific case, the rapid dissolution of the endoventricular thrombi.