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• W1970831432 abstract "Major pulmonary embolism (PE) can cause death from right-heart failure1Piazza G Goldhaber SZ The acutely decompensated right ventricle: pathways for diagnosis and management.Chest. 2005; 128: 1836-1852Abstract Full Text Full Text PDF PubMed Scopus (154) Google Scholar and, among survivors, may lead to disabling chronic thromboembolic PE.2Piazza G Goldhaber SZ Acute pulmonary embolism: part I. Epidemiology and diagnosis.Circulation. 2006; 114: e28-e32Crossref PubMed Scopus (131) Google Scholar Massive PE is rare but often obvious when it occurs during hospitalization. There is dramatic sudden onset of hypotension, tachycardia, and respiratory distress, often accompanied by new right bundle-branch block on the ECG. This medical emergency can be catastrophic and usually requires emergency thrombolysis or embolectomy in addition to intensive anticoagulation, vasopressors, and mechanical ventilation.3Kucher N Goldhaber SZ Management of massive pulmonary embolism.Circulation. 2005; 112: e28-e32Crossref PubMed Google Scholar In contrast, submassive PE is more common, but its presentation is often subtle and insidious. Initially, patients usually appear clinically stable. They always have preserved systemic arterial pressure, and at times even the heart rate and respiratory rate may be normal. Optimal management of submassive PE requires rapid and accurate risk stratification based on clinical assessment, cardiac biomarkers, and determination of right ventricular size and function.4Kucher N Goldhaber SZ Risk stratification of acute pulmonary embolism.Semin Thromb Haemost. 2006; 32: 838-847Crossref PubMed Scopus (52) Google Scholar The most validated risk-assessment tool is echocardiography. Right ventricular hypokinesis on echocardiography predicts a doubling of mortality within the next 30 days, even among initially normotensive patients.5Kucher N Rossi E De Rosa M et al.Prognostic role of echocardiography among patients with acute pulmonary embolism and a systolic arterial pressure of 90 mm Hg or higher.Arch Intern Med. 2005; 165: 1777-1781Crossref PubMed Scopus (346) Google Scholar Right ventricular enlargement on chest CT also portends a greater likelihood of death or major in-hospital complication.6Schoepf UJ Kucher N Kipfmueller F et al.Right ventricular enlargement on chest computed tomography: a predictor of early death in acute pulmonary embolism.Circulation. 2004; 110: 3276-3280Crossref PubMed Scopus (457) Google Scholar The case report elegantly presented and discussed by Kumar and colleagues7Kumar N Janjigian Y Schwartz DR Paradoxical worsening of shock after the use of percutaneous mechanical thrombectomy (PMT) device in a post partum patient with a massive pulmonary embolism.Chest. 2007; 132: 677-679Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar in this issue of CHEST (see page 677) highlights the benefits and risks of percutaneous mechanical thrombectomy (PMT). PMT was ultimately lifesaving for the reported patient, but the procedure was treacherous and caused nearly fatal iatrogenic complications. It is a double-edged sword. The special niche for PMT is among PE patients with adverse prognostic indicators who are not good candidates for thrombolysis because of a high risk of bleeding complications.8Fiumara K Kucher N Fanikos J et al.Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism.Am J Cardiol. 2006; 97: 127-129Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar My estimate is that no more than 4,000 such patients present themselves annually in the United States. Thus, PMT should be viewed therapeutically as analogous to an orphan drug. To date, PMT catheters have been developed primarily for the coronary arteries, not the pulmonary arteries. Available catheters tend to be either too small to extract sufficient clot or too large, predisposing to traumatizing the pulmonary arterial wall. The PMT catheter can perforate the pulmonary artery, cause massive distal embolization of thrombus, or cause hemolysis. These potential complications will worsen already tenuous hemodynamics. Therefore, operator experience and cardiac surgical backup are of paramount importance. Why has development and adoption of PMT progressed so slowly? First, the indications for PMT remain uncertain because our knowledge base is spotty. Most cases are performed under emergency, life-threatening circumstances that make organized clinical trials impractical. As a result, scattered case reports form the foundation of our practical experience. Second, catheter development is hampered by an economic disincentive: the rarity of PMT for acute PE compared, in contrast, with the frequency of percutaneous coronary intervention. Third, operator inexperience is rampant. I have found that I usually request PMT at night, during weekends, and during major national holidays. Inexplicably, the need for PMT for PE seems to eschew time periods when the hospital is fully staffed. Because interventional laboratories rotate on-call responsibilities, no single operator gains much individual experience. Furthermore, PMT seems to lack the cutting-edge appeal and glory of other interventional cardiovascular procedures. Therefore, few operators volunteer to “own” PMT at their interventional laboratories. The result is that many unwilling operators under the most trying of emergency circumstances must embark on a steep learning curve. Successful outcomes are the best incentive for mastering this narrow field. However, when dealing with these high-risk PE patients, major complications often do occur. Consequently, most interventionalists quickly lose their desire to master PMT because it is technically demanding, often frustrating, and usually performed with a skeletal backup staff during off-hours. Rarely is the operator or laboratory staff familiar with and comfortable with undertaking PMT. Therefore, major complications such as hemolysis can remain undiagnosed far longer than necessary, and the summoning of cardiac surgeons for “bail out” may be inappropriately delayed. This issue of CHEST (see page 657) includes Kucher's review of catheter embolectomy for acute PE.9Kucher N Catheter embolectomy for acute pulmonary embolism.Chest. 2007; 132: 657-663Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar It is the most comprehensive overview available and illustrates five very different types of catheters: the classic Greenfield embolectomy catheter, which requires a “cut-down” over the right internal jugular vein; the pigtail rotational catheter used for thrombus fragmentation; the Amplatz impeller device (MicroVena; White Bear Lake, MN), which pulverizes thrombus; the Rheolytic catheter (eg, Possis Medical; Minneapolis, MN), which creates a Venturi effect with high-velocity saline solution injection; and the Aspirex device (Straub Medical; Wangs, Switzerland) designed for large caliber pulmonary arteries, which uses a rotational coil within the catheter to create negative pressure that aspirates, macerates, and removes thrombus fragments. A call for controlled clinical trials of PMT is unrealistic. The procedure itself is in evolution, and few would consider themselves master teachers of the technique. There is probably no appropriate comparison group. After all, the proper role of PMT is when therapy must be escalated beyond anticoagulation. The first adjunct to consider is thrombolysis.10Goldhaber SZ A contemporary approach to thrombolytic therapy for pulmonary embolism.Vasc Med. 2000; 5: 115-123Crossref PubMed Google Scholar The next step is embolectomy, either with PMT or with an open surgical procedure.11Leacche M Unic D Goldhaber SZ et al.Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach.J Thorac Cardiovasc Surg. 2005; 129: 1018-1023Abstract Full Text Full Text PDF PubMed Scopus (306) Google Scholar PMT for acute PE is a risky, high-stakes proposition. Ideally, only operators who plan to specialize in this technique should undertake the procedure. They must, as a prerequisite, be entirely comfortable managing critically ill patients. Often the medical management of these PE patients suffers while they are draped for PMT. Some pairs of eyes should be trained on the angiographic images. But meticulous attention is also required simultaneously for ongoing vasopressor, fluid, electrolyte, and ventilator management of these desperately ill patients. This includes continuous assessment of volume status, urine output, and end-organ perfusion during PMT. Patients who may require PMT should be transferred emergently to centers of excellence that specialize in the procedure. As with PE thrombolysis,12Goldhaber SZ Thrombolytic therapy for patients with pulmonary embolism who are hemodynamically stable but have right ventricular dysfunction: pro.Arch Intern Med. 2005; 165 (discussion 2204–2205): 2197-2199Crossref PubMed Scopus (47) Google Scholar PMT is best undertaken prior to the development of sustained hypotension. The intervention should be initiated early to minimize the potential downhill spiral of cardiogenic shock and multisystem organ failure. However, the procedure should not be started too soon if it is likely that patients will recover fully with conservative measures alone. For the past decade, I have wanted someone to establish a global registry so that we can track the evolving experience with PMT. This has not happened, even though registries abound in acute coronary syndrome and venous thromboembolism. Kumar and colleagues7Kumar N Janjigian Y Schwartz DR Paradoxical worsening of shock after the use of percutaneous mechanical thrombectomy (PMT) device in a post partum patient with a massive pulmonary embolism.Chest. 2007; 132: 677-679Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar have spurred me to action. I hereby announce that I will establish a working group, sponsored by the Brigham and Women's Hospital Venous Thromboembolism Research Group and endorsed by nonprofit organizations such as the North American Thrombosis Forum (www.NATFonline.org). PMT will become the focus of a collaborative worldwide effort. Our first objective will be to launch a Web-based global registry. We will also encourage the development of improved PMT catheters.13Kucher N Windecker S Banz Y et al.Percutaneous catheter thrombectomy device for acute pulmonary embolism:in vitroandin vivotesting.Radiology. 2005; 236: 852-858Crossref PubMed Scopus (71) Google Scholar Finally, if resources permit, we will work with foundations to establish traveling fellowships that allow free and fertile exchange of ideas to move this field forward. A full discussion of ideas and experiences will transform PMT from a double-edged sword to a precisely applied tool in our PE management armamentarium. Through our collective action, we will optimize and standardize this promising technique. Ultimately, detailed standardized protocols on PMT indications and techniques, coupled with top-notch training programs, will be developed to ensure that we move the field forward so that PMT emerges from its infancy." @default.
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