0
Communications to the Editor |

Treatment of Right Heart Thromboemboli With IV Recombinant Tissue-Type Plasminogen Activator FREE TO VIEW

Michel Procopiou, MD; Arnaud Perrier, MD
Author and Funding Information

Affiliations: Hôpital Cantonal Geneva, Switzerland,  Ospedale Civile Cosenza, Italy

Correspondence to: Michel Procopiou, MD, Department of Internal Medicine, Medical Clinic 1, Hôpital Cantonal, CH 1211 Geneva 14, Switzerland; e-mail: Michel.Procopiou@hcuge.ch



Chest. 2000;117(3):920-921. doi:10.1378/chest.117.3.920
Text Size: A A A
Published online

To the Editor:

We read with interest the recent article by Greco and colleagues (July 1999).1 Among 30 patients admitted to their ICU with massive pulmonary embolism (PE), they detected 7 patients with right heart thromboemboli (RHTE) who were immediately treated with recombinant tissue-type plasminogen activator. This treatment was followed with rapid resolution of thrombus and improvement of hemodynamic status and echocardiographic parameters of acute right ventricular overload. In our opinion, this study raises two major questions.

First, in patients with massive PE, is the finding of RHTE really a“ life-threatening event”?1The high mortality rate of 40% was based on pooled case reports or case series.23 The majority of these patients presented with a dramatic clinical picture of massive PE3(New York Heart Association class IV dyspnea, cardiogenic shock), which prompted echocardiographic evaluation. The prevalence of RHTE in nonmassive PE is unknown. In an observational study of 130 patients with massive PE, RHTE was present in 23 patients (18%) and did not carry a higher mortality than in patients without RHTE (30% vs 24%).4There was no statistical difference in treatment allocation (heparin vs thrombolysis) between the two groups. RHTE might just represent an incidental finding, the bad prognosis being in fact due to massive PE. Indeed, massive PE complicated by shock has a high mortality rate (18 to 38%) by itself.5

Second, what is the efficacy of thrombolytic therapy in the setting of RHTE? The fact that RHTE might not have an isolated prognostic significance raises strong doubts about the relevance of any specific treatment (thrombolytic agents or surgical thrombectomy) other than therapeutic anticoagulation. The study by Greco and colleagues1 showed disappearance of the thrombus and improvement of different hemodynamic variables. Thrombolytic therapy in PE quickly improves lung scans and angiographic or echocardiographic findings but has not been shown to reduce mortality.5 Moreover, thrombolytic therapy could double the number with severe bleeding (as compared with patients treated with heparin).5 In the study by Casazza et al,4 5 of the 18 patients with massive PE and RHTE were treated with anticoagulant therapy and showed disappearance of the thrombus after several days without new symptoms.

In conclusion, we estimate that data on RHTE are too scarce to allow a conclusion on the benefits of thrombolytic therapy over anticoagulation in patients with PE and RHTE but no hemodynamic compromise. However, patients with massive PE and shock should receive thrombolytic treatment whether RHTE are present or not.

References

Greco, F, Bisignani, G, Serafini, O, et al (1999) Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report.Chest116,78-82. [PubMed] [CrossRef]
 
European Working Group on Echocardiography. The European Cooperative Study on the clinical significance of right heart thrombi.Eur Heart J1989;10,1046-1059. [PubMed]
 
Chartier, L, Béra, J, Delomez, M, et al Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.Circulation1999;99,2779-2783. [PubMed]
 
Casazza, F, Bongarzoni, A, Centoze, F, et al Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.Am J Cardiol1997;79,1433-1435. [PubMed]
 
Dalen, JE, Alpert, JS, Hirsh, J Thrombolytic therapy for pulmonary embolism. Is it effective? Is it safe? When is it indicated?Arch Intern Med1997;157,2550-2556. [PubMed]
 
To the Editor:

The questions raised by Dr. Procopiou regarding our recent publication in CHEST (July 1999)1 confirm the great doubts and uncertainties that still exist about management of right heart thromboemboli (RHTE) detected by echocardiography during pulmonary embolism (PE). At the present time, prevalance and treatment of RHTE remain as two major unresolved problems. Prognostic significance, apparently clear and well defined, seems to be emerging as another question.

We know from the literature that detection of RHTE is commonly associated with proximal deep venous thrombosis and massive PE, frequently in cardiogenic shock.2 This complex clinical condition presents as a severe thromboembolic disease, with a proven high rate of short-term mortality.23

The retrospective study of Dr. Casazza et al4 points out how the bad prognosis of these patients is probably the result of massive PE rather than RHTE itself, so that anticoagulation can be proposed as treatment of choice of RHTE in hemodynamic stability.4

In the European Cooperative Study, the heparin group registered a high mortality rate and, although Tavel et al5 suggest adding a vena cava filter to heparin infusion in hemodynamically stable patients with RHTE, this novel approach should be confirmed in term of efficacy.2,5Moreover, even if we do not believe that treatment of RHTE with thrombolysis or surgical embolectomy will prevent an unpredictable and castastrophic embolization of these large floating clots in a pulmonary tree, where major embolisms had often previously occurred, we have seen that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with massive PE.6Thrombolysis over heparin leads to a rapid improvement of pulmonary perfusion and right ventricular function, with a lower rate of recurrent PE and death.7Finally, intracranial hemorrhage after PE thrombolysis is an infrequent complication.8

We believe, therefore, that thrombolysis can be the first-choice therapy, effective and safe, in this particular condition that we call RHTE syndrome (RHTE plus massive PE and proximal deep venous thrombosis), a critical and high-mortality clinical-instrumental picture. The term “life-threatening event” can reasonably summarize the latter concept. However, until a prospective, multicenter, randomized treatment trial is realized, the debate is far from over.

References
Greco, F, Bisignani, B, Serafini, O, et al Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report.Chest1999;116,78-82. [PubMed] [CrossRef]
 
European Working Group on Echocardiography. The European Cooperative Study on the clinical significance of right heart thrombi.Eur Heart J1989;10,1046-1059. [PubMed]
 
Farfel, Z, Shechter, M, Vered, Z, et al Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management.Am Heart J1987;113,171-178. [PubMed]
 
Casazza, F, Bongarzoni, A, Centonze, F, et al Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.Am J Cardiol1997;79,1433-1435. [PubMed]
 
Tavel, ME, Goldhaber, SZ, Moser, KM Rapidly progressing dyspnea associated with a mass in the right side of the heart.Chest1995;107,866-868. [PubMed]
 
Konstantinides, S, Geibel, A, Olschewski, M, et al Impact of thrombolytic treatment on the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry.Circulation1997;96,882-888. [PubMed]
 
Goldhaber, SZ Pulmonary embolism.N Engl J Med1998;339,93-104. [PubMed]
 
Kanter, DS, Mikkola, KM, Patel, SR, et al Thrombolytic therapy for pulmonary embolism: frequency of intracranial hemorrhage and associated risk factors.Chest1997;111,1241-1245. [PubMed]
 

Figures

Tables

References

Greco, F, Bisignani, G, Serafini, O, et al (1999) Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report.Chest116,78-82. [PubMed] [CrossRef]
 
European Working Group on Echocardiography. The European Cooperative Study on the clinical significance of right heart thrombi.Eur Heart J1989;10,1046-1059. [PubMed]
 
Chartier, L, Béra, J, Delomez, M, et al Free-floating thrombi in the right heart: diagnosis, management, and prognostic indexes in 38 consecutive patients.Circulation1999;99,2779-2783. [PubMed]
 
Casazza, F, Bongarzoni, A, Centoze, F, et al Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.Am J Cardiol1997;79,1433-1435. [PubMed]
 
Dalen, JE, Alpert, JS, Hirsh, J Thrombolytic therapy for pulmonary embolism. Is it effective? Is it safe? When is it indicated?Arch Intern Med1997;157,2550-2556. [PubMed]
 
Greco, F, Bisignani, B, Serafini, O, et al Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: a case series report.Chest1999;116,78-82. [PubMed] [CrossRef]
 
European Working Group on Echocardiography. The European Cooperative Study on the clinical significance of right heart thrombi.Eur Heart J1989;10,1046-1059. [PubMed]
 
Farfel, Z, Shechter, M, Vered, Z, et al Review of echocardiographically diagnosed right heart entrapment of pulmonary emboli-in-transit with emphasis on management.Am Heart J1987;113,171-178. [PubMed]
 
Casazza, F, Bongarzoni, A, Centonze, F, et al Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism.Am J Cardiol1997;79,1433-1435. [PubMed]
 
Tavel, ME, Goldhaber, SZ, Moser, KM Rapidly progressing dyspnea associated with a mass in the right side of the heart.Chest1995;107,866-868. [PubMed]
 
Konstantinides, S, Geibel, A, Olschewski, M, et al Impact of thrombolytic treatment on the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry.Circulation1997;96,882-888. [PubMed]
 
Goldhaber, SZ Pulmonary embolism.N Engl J Med1998;339,93-104. [PubMed]
 
Kanter, DS, Mikkola, KM, Patel, SR, et al Thrombolytic therapy for pulmonary embolism: frequency of intracranial hemorrhage and associated risk factors.Chest1997;111,1241-1245. [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543