Affiliations: Hôpital Cantonal
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
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
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.2–3
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.
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.2–3
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
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
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.
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