Presentación de "High risk pulmonary embolism" por el Dr David Jimenez del Hospital Ramón y Cajal, en el I Curso IVP, Intervencionismo Vascular Pulmonar, organizado por EpicLearning (Fundación EPIC) el 23 de marzo de 2021.

1. David Jiménez, MD, PhD, FCCP, FERS
Hospital Ramón y Cajal, IRYCIS
Madrid, Spain
High-risk pulmonary embolism

2. Disclosures for Dr. Jimenez
Research support Daiichi Sankyo, Sanofi
Employee No relevant conflicts of interest to declare
Consultant and/or honoraria
Bayer, Boehringer Ingelheim, BMS,
Daiichi Sankyo, Leo Pharma, Pfizer, ROVI,
Sanofi
Stockholder No relevant conflicts of interest to declare
Speakers bureau Bayer, BMS, Sanofi
Scientific advisory board See consultant

3. Quezada CA, Am J Cardiol 2019
High-risk PE
Prevalence: 3.9%

4. Success with
hemodynamic improvement
Very
high-risk PE
Unsuccessful
Unsuccessful
Cardiac arrest
Hemodynamic instability
Stabilization with
fluid loading/vasopressors
Catheter-directed therapy
PERT 24/7
High-risk PE
Further hemodynamic
compromise
Unsuccessful
Systemic thrombolysis
Surgical embolectomy ECMO
If no severe
brain injury
If progressive
support required
Refractory shock
Resuscitated
cardiac arrest
Refractory
cardiac arrest
Cardiopulmonary resuscitation

5. 39,257 patients from the RIETE registry 1/2001-08/2018.
Jiménez D, BMJ 2019
Pulmonary Embolism Response Teams

6. Reperfusion for high-risk PE
1,207 patients with unstable PE from the RIETE registry
• 20% (95% CI, 18-22%) of unstable patients received
reperfusion therapy
• Reperfusion therapy reduced by 47% 30-day all-cause
mortality
• Reperfusion therapy reduced by 69% 30-day PE-
related death
Jiménez D, Int J Cardiol 2018

7. Thrombolytics for high-risk PE
Jerjes Sanchez C, J Thromb Thrombolysis 1995
• Eight patients randomized to streptokinase plus
heparin or heparin alone
• All four patients treated with heparin alone died

8. Systemic thrombolysis
Chatterjee S, JAMA 2014

9. Tapson V, Semin Respir Crit Care Med 2017
Catheter-directed interventions

10. Reduced doses of lytics
121 patients with “moderate” PE from a single center
Variable TG
(N = 58)
CG
(N = 56)
P value
Recurrent PE 0 3 (5%) 0.08
Total mortality 1 (1.6%) 3 (5%) 0.30
Total mortality plus
recurrent PE
1 (1.6%) 6 (10%) 0.049
Bleeding 0 0 -
Sharifi M, Am J Cardiol 2012

11. P<0.0001
ULTIMA trial
Kucher N, Circulation 2014
59 patients with PE and RV dilation

12. P<0.0001
Surgical embolectomy
Kalra R, Ann Thorac Surg 2017
1,590 patients from 56 studies

13. Jimenez D, Thorax 2018
Reperfusion strategies for acute PE
Low-dose thrombolysis
Local thrombolysis
Full-dose thrombolysis
Anticoagulation

14. Thrombolysis
contraindicated
No Relative Absolute
Reperfusion
treatment
Full-dose
systemic
TPA
Low-dose
systemic TPA
or
Catheter-
directed
thrombolysis
Surgical
embolectomy
or
Percutaneous
embolectomy
Spanish recommendations
Lobo JL, Arch Bronconeumol 2021

15. P<0.0001
CDT and surgical embolectomy
Study N CDT 30-day survival ECMO duration
Munakata 2012 10 Pig-tail* 70% 48 ± 44 hours
Maj 2014 2 EKOS 50% 2-10 days
George 2018 15 EKOS 73% _
Dumantepe 2019 21 EKOS 76% 5.5 [2-14] days
Overall 73%
* fragmentation, thrombectomy, lysis infusion

16. P<0.0001
ECMO and surgical embolectomy
Ius F, Eur Respir J 2019
Overall in-hospital survival rate = 95%
The decision on definitive therapy after establishment
of VA ECMO support was made by the PERT with
surgical treatment being the preferred strategy.

17. VA ECMO in high-risk PE patients
584 patients from 66 studies
Baldetti L, Eur Heart J 2020

18. Conclusions
• Activate PERT
• Follow clinical practice guidelines
• Systemic thrombolysis whenever possible
• ECMO as a lifesaving therapy