Page 17 - Highlights of Napcon 2021

Thrombolysis and Surgery in PE: When and Why?

Dr. Amina Mobashir

Consultant, Respiratory Critical Care Medicine
Max Hospital, Saket
New Delhi

Dr. Amina Mobashir began her presentation by explaining factors that are predictive of poor prognosis in pulmonary
embolism. Among these, persistent hypotension or shock despite adequate resuscitation is an important one.
Thrombolysis improves pulmonary artery (PA) pressure, right ventricular (RV) function, and pulmonary perfusion
more quickly than heparin alone. While data is limited, improvements in mortality are seen, despite at an expense
of increased risk of bleeding. Explaining these aspects, Dr. Mobashir pointed out that a meta-analysis of 16 trials
indicate reduced rates of recurrent thromboembolism following thrombolysis. The presentation noted that high-
risk pulmonary embolism with low bleeding risk and intermediate high-risk pulmonary embolism are absolute and
relative indications for thrombolysis, respectively (Figures 1 and 2).

ABSOLUTE INDICATION- the high risk group with low Acute PE without hypotension but
bleeding risk with evidence of abnormal RV
function by echocardiography
Hemodynamic ‡ 6\VWROLF%3PP+J and an elevated troponin and/or
instability ‡ 9DVRSUHVVRUV
‡ 'HFUHDVHLQWKH6%3E\ brain natriuretic peptide (BNP) level
simplified pulmonary embolism
•PP+JIURPEDVHOLQH severity index (sPESI) score >0
IRUPLQXWHVRUORQJHU

Figure 1: Absolute Indication- the high-risk Figure 2: Intermediate high risk pulmonary
group with low bleeding risk embolism: relative indication for thrombolysis

Explaining the usefulness of thrombolysis in the intermediate high-risk group, the presentation went on to explain
the results of the Pulmonary Embolism THrOmbolysis (PETHO) trial, which indicated a reduction in death or
hemodynamic decompensation at seven days with heparin + tenecteplase compared with heparin alone. Similar
findings have been reported from meta-analysis. Dr. Mobashir then went on to say that systemic-or catheter-directed
thrombolysis may be useful in patients who deteriorate due to pulmonary embolism while on anticoagulant therapy.

Dr. Mobashir then went to explain the experience at Saket Hospital, New Delhi including systemic thrombolysis, low
dose systemic thrombolysis, catheter-directed thrombolysis, and surgical embolectomy. Overall, the presentation
emphasized that the treatment of pulmonary embolism should be personalized. Furthermore, approaches for
managing pulmonary embolism must consider the severity of illness, baseline cardiopulmonary reserve, and bleeding
risk.

Highlights of NAPCON 2021 15