Contemporary Management of Pulmonary Embolism

1
Contemporary Management of Pulmonary Embolism

• Lowell I. Gerber M.D.
• Associate Professor of Medicine
• KCOM

2
PULMONARY EMBOLISM

• Estimated 650,000 cases annually in the US
• Third most common cause of death in US
• 50,000 to 200,000 deaths per year
• 15 of all in-hospital deaths
• Difficult to diagnose
• Approx. 10 of patients in whom diagnosis is
  established die within first 60 minutes

3
MASSIVE PULMONARY EMBOLISM
Estimated 10 of all PE 3-7X increased
mortality over non-massive PE UPET 36 vs
5 ICOPER 58 vs 15 MAPPET 31
4
PULMONARY EMBOLISMPATHOLOGY
5
PULMONARY EMBOLISMPATHOPHYSIOLOGY
6
THE SPECTRUM OF PULMONARY EMBOLISM
Hemodynamic Instability
Right Ventricular Dysfunction
Stable Hemodynamics and Cardiac Function
7
CLINICAL RISK FACTORS FOR VTE

• AGE gt 40
• MAJOR SURGERY OR TRAUMA
• IMMOBILIZATION
• VENOUS STASIS
• OBESITY
• DIABETES
• FRACTURE
• VARICOSE VEINS

• CHF , MI, CVA
• PRIORHX VTE HIP
• PREGNANCY / POSTPARTUM
• CONTRACEPTIVES
• CANCER
• ANTIPHOSPHOLIPID AB SYNDROME

8
HERITABLE RISK FACTORS FOR VTE

• FACTOR V LEIDEN MUTATION
• HYPERHOMOCYSTEINEMIA
• PROTEIN C DEFICIENCY
• RESISTANCE TO ACTIVATED PROTEIN C
• PROTEIN S DEFICIENCY
• ANTITHROMBIN III DEFICIENCY

9
HERITABLE RISK FACTORS FOR VTE

• PROTHROMBIN MUTATION G20210A
• HEPARIN COFACTOR II
• DYSFIBRINOGENEMIA
• DYSPLASMINOGENEMIA

10
RISK STRATIFICATION
VARIABLE
HAZARD RATIO (95 CI) Age gt70 years
1.6 (1.1-2.3) COPD

1.8 (1.2-2.7) Systolic blood pressure lt90mmHg
2.9 (1.7-5.0) Right ventricular hypokinesis
2.0 (1.3-2.9) Congestive Heart Failure
2.4 (1.5-3.7) Cancer
2.3
(1.5-3.5) Respiratory rate lt20/min
2.0 (1.2-3.2)
Goldhaber, et al. Lancet.3531386-89 24 Apr 1999
11
RISK STRATIFICATIONUsing a Clinical Decision
Rule

• Clinical signs and symptoms of DVT 3.0
• Alternative diagnosis less likely than PE 3.0
• Heart rate gt100/min 1.5
• Immobilization (gt3days) or surgery in 4wks 1.5
• Previous PE or DVT 1.5
• Hemoptysis 1.0
• Malignancy (Rxing or Rxed in last 6 mos) 1.0
• gt4 pts Clinical probability of PE is likely
• 4 or less pts Clinical probability of PE is
  unlikely

Wells, et al Thromb Haemost 200083416-420
12
MORTALITY PE/DVT IN ELDERLY
INHOSPITAL 1 YEAR 21 / 3
39 / 21
Kniffin et al. Arch Intern Med. 1994 Apr 25
13
CLINICAL PROFILE PE
SYMPTOMS FREQUENCY
() DYSPNEA
73 PLEURITIC PAIN
66 COUGH
37 LEG SWELLING / PAIN
28 / 26 SIGNS
FREQUENCY
() TACHYPNEA (gt20/MIN)
70 RALES
51 TACHYCARDIA
30 S4 / INCREASED S2
24 / 23
STEIN, P.D. ET AL. CHEST 100598, 1991
14
CXR

PULMONARY VASCULATURE
ENLARGED RIGHT DESCENDING PULMONARY ARTERY
WEDGE-SHAPED INFILTRATE
OFTEN NORMAL
15
ELECTROCARDIOGRAM PULMONARY EMBOLISM
T-wave inversion in leads III, aVF, or in leads
V1-V4
QS in leads III and aVF

Incomplete or complete right bundle branch block
QRS axis gt 90 or indeterminate axis
Transition zone shift to V5
16
ELECTROCARDIOGRAM PULMONARY EMBOLISM

• S1,Q3,T3 most specific
• Normal or Sinus Tachycardia most frequent

17
LABORATORY TESTING D-DIMER ELISA

• Sensitive but nonspecific test for PE
• High negative predictive value when
  concentrations lt500ng/ml
• Omit if high clinical suspicion or patient with
  systemic illness

Goldhaber, et al. JAMA. 1993. 2702819-2822 Bounam
eaux, et al. Thromb Haemost. 1994 71 1-6
18
LABORATORY TESTINGBioMarkers in Pulmonary
Embolism
19
LABORATORY TESTINGBioMarkers in Pulmonary
Embolism BNP

• Normal BNP Benign Prognosis
• Elevated BNP associated with adverse outcome
• Other causes of elevated BNP in RV pressure
  overload
• Primary pulmonary hypertension
• Chronic thromboembolic pulmonary hypertension
• Chronic lung disease

Circulation. 2003 Apr 1107(12)1576-8
20
LABORATORY TESTINGBioMarkers in Pulmonary
Embolism Troponin

21
LABORATORY TESTINGBioMarkers in Pulmonary
Embolism Troponin
22
LABORATORY TESTINGBioMarkers in Pulmonary
Embolism Troponin

• In acute pulmonary embolism elevated troponin
  levels have been shown to predict an adverse
  outcome.
• Serum troponin levels should help stratify
  patients with submassive acute pulmonary embolism
  into a group in which aggressive medical or
  surgical intervention would be considered

Curr Opin Pulm Med. 2003 Sep9(5)374-7.
23
V/Q SCAN
NORMAL PERFUSION
ABNORMAL PERFUSION
NORMAL- AND HIGH-PROBABILITY SCANS ARE CONSIDERED
DIAGNOSTIC
24
PIOPED PREDICTIVE VALUE V/Q SCAN
SCAN CATEGORY CLINICAL SUSPICION
80-100
20-79 0-19 HIGH
96 88 56 INTERMEDIATE
66 28 16 LOW
40
16 4
PIOPED INVESTIGATORS. JAMA.1990 263 2753-2759
25
PULMONARY ANGIOGRAPHY

• Gold Standard
• Death in 0.5
• Major, nonfatal complications in 1
• Visualizes distal segments
• Role in primary therapy for PE

26
ANGIOGRAPHIC SEVERITY SCORING
Miller, et al. Amer Journ Roent,Rad Therapy Nuc
Med. 125(4)895-9, 1975 Dec.
27
Multi Slice CT
92 SENSITIVITY , 95 SPECIFICITY COMPARED TO
ANGIOGRAPHY OR TO HIGH-PROB OR NORMAL SCINTIGRAM
(3rd generation scanner, 1mm slice thickness)
van Rossum,et al.Radiology.1996201467-70
28
Multi Slice CT
29
Effectiveness of Managing Suspected Pulmonary
Embolism Using an Algorithm Combining Clinical
Probability, D-Dimer Testing, and Computed
Tomography
JAMA 2006 295172-179 January 11, 2006
Writing Group for the Christopher Study
Investigators
30
Effectiveness of Managing Suspected Pulmonary
Embolism Using an Algorithm Combining Clinical
Probability, D-Dimer and CT
31
VTE Events During 3 month F/U in 3138 patients
Pts Total VTE Fatal PE

• PE unlikely and Nl D-Dimer 1028 5(0.5) 0(0)
• PE excluded by CT 1436 18(1.3) 7(0.5)
• CT Normal 764 9(1.2) 3().4)
• CT alternative Dx 672 9(1.3) 4(0.6)
• PE diagnosed by CT 674 20(3) 11(1.6)
• mortality 7.2 (55)
• Inconclusive CT 20 2by V/Q, 1/18
  non-fatal PE
• mortality 5 (1/20)
• CT indicated but not done 50 3by V/Q, 2 had
  DVT by CUS
• 1/45 fatal PE,
• mortality 14 (7/50)

32
ECHOCARDIOGRAPHY PULMONARY EMBOLISM

• Direct visualization of thrombus
• Right ventricular dilatation hypokinesis
  (except apex, McConnells sign)
• Abnormal interventricular septal motion
• Tricuspid valve regurgitation gt2.8 m/s
• Lack of decreased inspiratory collapse of
  inferior vena cava

33
TRANS ESOPHAGEAL ECHOCARDIOGRAPHYAND PATENT
FORAMEN OVALEin PULMONARY EMBOLISM

• Patent foramen ovale detected on TEE is an
  important predictor of adverse outcome in
  patients with major pulmonary embolism.
• These patients had a death rate of 33 as
  opposed to 14 in patients without PFO
• There is significantly higher incidence of
  ischemic stroke (13 versus 2.2 P.02) and
  peripheral arterial embolism (15 versus 0
  Plt.001).
• Overall, the risk of a complicated in-hospital
  course was 5.2 times higher in this patient group
  (Plt.001).

 

• Circulation. 1999 Jun 2999(25)3323.

34
RV OVERLOAD
DIASTOLE
SYSTOLE
RV DILATATION ABNORMAL SEPTAL MOTION
35
MORTALITY RV DYSFUNCTION
RV HYPOKINESIS
NO RV HYPOKINESIS
Goldhaber, et al. Lancet. 353 1386-8924 April
1999
36
PRIMARY THERAPY VS SECONDARY PREVENTION
NORMAL BP
RV DYSFUNCTION
SBPlt90
HEPARIN
THROMBOLYSIS MECHANICAL INTERVENTION
37
Heparin Anticoagulation

• While diagnostic work-up in progress begin with
  UFH 80/kg IV bolus, then 18 U/kg per hour, target
  PTT 60-80 secs
• Rapid reversibility for patients who may require
  thrombolysis, thrombectomy, or who have
  alternative diagnosis

38
Heparin Anticoagulation

• For stable patients recommendations include
  either weight based protocols for UFH, or
• Low Molecular weight heparin, trials suggest
  better efficacy with less bleeding
• LMWH can be considered as alternative to oral
  anticoagulation
• Monitor platelet counts and CBC
• When HIT complicates therapy, use direct thrombin
  inhibitors
• Argatroban
• Lepirudin

39
Low Molecular Weight Heparins
40
THROMBOLYSISUNSTABLE PATIENTS
Jerges-Sanchez et al. J Thromb Thrombolysis
19952227-229
41
Cardiac CT
42
Cardiac CT
43
THROMBOLYSIS RV DYSFUNCTION
Goldhaber et al. The Lancet 3418844 507-511,
Feb 27 1993
44
THROMBOLYSIS STABLE MAJOR PE
Konstantinides S et al. Circulation.
199796882-888
45
THROMBOLYSIS STABLE MAJOR PE
ONLY INDEPENDENT PREDICTOR OF SURVIVAL (719
PATIENTS)
Konstantinides et al. Circulation.199796882-888
46
Management Strategies and Prognosis of Pulmonary
EmobolismMAPPET-3

• Rt-PA Heparin vs Heparin alone
• 256 patients with RV dysfunction but no
  hypotension/shock
• Primary endpoint death or escalation of therapy
  eg need for catecholamine, thrombolytics, CPR,
  intubation, embolectomy
• Primary endpoint achieved in 25 of patients with
  heparin alone vs 10 patients with rt-PA plus
  heparin (p0.006)
• No ICH in the controlled trial
• ICH occurred in 3.0 of 304 patients receiving
  thrombolytics in registry (2454 pts)

NEJM 2002 3471143
47
THROMBOLYSIS CONTRAINDICATIONS

• Active internal bleed
• CVA
• Diastolic HTNgt110
• Surgery lt 10 days
• CPR
• Pregnancy
• Post-partum lt 10 days
• Trauma

48
THROMBOLYSIS COMPLICATIONS

• Major bleeding frequency after noninvasive
  diagnosis 4.2
• Major bleeding frequency after invasive
  diagnosis 14
• Fewer complications would occur with noninvasive
  management

Stein et al.Annals of Internal Medicine.121313-31
7, Sept 1994
49
THROMBOLYSISIN-VITRO

• Streptokinase has slowest rate of clot lysis.
• Urokinase has intermediate rate of clot lysis,
  but most fibrinolytic specificity.
• rt-PA improved efficacy early, but rt-PA and
  urokinase difference dissipated after 30 min.

Ouriel K, et al. J Vasc Surg. 1995 22 593-597
50
Thrombolytic Regimens for Pulmonary Embolism

• Streptokinase 250K loading dose IV over 30min
  followed by 100K U/hr for 24 hr (FDA ok)
• Alteplase(t-PA) 100mg, peripheral IV infused
  over 2 hrs
• (FDA ok)
• Urokinase 2000 U/lb IV loading dose over 10 min,
  then 2000 U/lb per hour for 12 to 24 hours (FDA
  ok)
• Reteplase (retavase) 10U IV over 2min,
• then 30 min later 10U over 2 min

51
Potential Indications for Thrombolytic Therapy
for VTE

• Commonly Accepted
• Presence of hypotension or hemodynamic
  instability
• Careful Case Selection
• Presence of severe hypoxemia
• Substantial perfusion defect V/Q or thrombus
  burden CT
• Right ventricular dysfunction associated with PE
• Concomitant extensive deep vein thrombosis
• Free-floating RA/RV thrombus
• Patent Foramen Ovale (PFO) / paradoxical embolus

52
PERCUTANEOUS
53
PERCUTANEOUS INTERVENTION

• 1969- Greenfield Vacuum pump embolectomy
• 1994- Mazeika Percutaneous catheter
  fragmentation
• 1994- Dievart Angiocor Thrombolizer
• 1995- Scmitz-Rode Pigtail catheter fragmentation
• 1996- Uflacker Amplatz thrombectomy device
• 1997- Koning Rheolytic thrombectomy catheter

54
UROKINASE INTRAPULMONARY INFUSION

• 26 patients with PE received intrapulmonary
  arterial infusions of urokinase.
• 9/26 had systemic thrombolytic contraindications.
• 20 pts returned to baseline state, 1 minimal
  change, 5 deaths

McCotter,C.J. et al. Clin. Cardiol.22, 661-664
(1999)
55
PULMONARY INTRATHROMBUSINFUSION
56
THROMBOLYSIS AND FRAGMENTATION
57
IVC FILTERS

• TWO PRINCIPAL INDICATIONS
• Absolute contraindication to anticoagulation or
  complication of anticoagulation therapy.
• Recurrent PE despite adequate duration and level
  of anticoagulation, or patient not likely to
• survive a recurrent PE because of tenuous
  hemodynamic status and iliofemoral thrombus
  burden.

58
IVC FILTERS

• Do not prevent further thrombosis
• Serve as a nidus for recurrent thrombus
• Re-hospitalization within 1 year of filter
  placement for recurrent VTE 2.6 X control.

Arch Intern Med 2000 1602033
59
CURRENT PERMANENT IVC FILTERS
Birds Nest
Stainless steel
Greenfield
Simon Nitinol
Titanium
Vena Tech
60
RETRIEVABLE VENA CAVA FILTERS

• Recovery Nitinol Filter
• Gunther Tulip Filter
• OptEase Filter

61
Recovery Nitinol Filter

• Bard Peripheral Vascular, Tempe, AZ
• First FDA approved retrievable filter has no
  barbs for fixation, and therefore has a much
  longer potential window for retrieval.
• One group has reported successful retrieval of
  filters as long as 134 days after insertion.
  There was, however, one filter that migrated
  after clot capture.
• This emphasizes the one minor weakness of
  retrievable filters with extended placement
  times these filters may have less surface area
  of contact with the vena cava to avoid tissue
  ingrowth and fixation.

62
Gunther Tulip Filter
(Cook Inc., Bloomington, IN) has perhaps the
widest experience in both the US and Europe.
There are several reports in the literature
supporting its value as a temporary filter It
has the capability of deployment from either a
femoral or jugular route. It must be retrieved
from a jugular vein approach. Most authors
recommended retrieval within 14 days.
63
OptEase Filter
Cordis Endovascular, a Johnson Johnson company,
Miami, FL Has a unique self-centering design
that provides dual-level filtration. It can be
deployed from both the transfemoral and
transjugular approaches using the same kit. It
is the only potentially retrievable filter that
is recovered from a femoral vein approach and
requires a small retrieval system (10F guiding
catheter)
64
NEW AND PROPHYLACTIC APPLICATIONSOF IVC FILTERS

• Trauma and major orthopedic surgery will most
  likely encompass the greatest use of retrievable
  vena cava filters
• With the increasing number of obese patients
  undergoing major operations and bariatric
  surgery, the use of retrievable filters will
  continue to grow.
• Ongoing prospective studies will probably
  support elevated body mass index as a major
  predictor of pulmonary embolism and will have a
  tremendous impact on the future of retrievable
  vena cava filters.

65
NEW AND PROPHYLACTIC APPLICATIONSOF IVC FILTERS

• Patients with DVT but no PE
• Reduced cardiopulmonary function, would not
  tolerate a PE
• Free-floating DVT despite adequate anticoag
• Recent DVT, undergoing major surgery
• Pregnancy with proximal DVT, undergoing
• catheter directed therapy

66
PROPHYLACTIC APPLICATIONSOF IVC FILTERS

• The treatment of extensive iliofemoral deep
  venous thrombosis with thrombolytic therapy or
  surgical thrombectomy can cause pulmonary
  embolism during the procedure. Although permanent
  vena cava filters
• have been used in this setting, retrieval
  of the filter after resolution of the deep vein
  thrombosis is appealing.
• Patients with Neurological Problems resulting in
  prolonged immobilization, paralysis, stroke with
  DVT.
• Patients with advanced malignancy and
  chemotherapy
• Patients with suspected hypercoagulable state
• Case reports in the literature cite success in
  the use of retrievable vena cava filters for
  pregnant patients with thromboembolism
• Retrievable vena cava filters off label as
  temporary filters during resection of renal cell
  cancers
• with tumor thrombus extension into the inferior
  vena cava.

67
FUTURE APPLICATIONSOF IVC FILTERS
. Patent Foramen
Ovale Recognized as a major contributor to
morbidity and mortality Combined procedures of
IVC filter and PFO closure may become more
frequent

68
RHEOLYTIC THROMBECTOMY CATHETER
69
RHEOLYTIC THROMBECTOMY CATHETER
70
RHEOLYTIC THROMBECTOMY CATHETER
71
PERCUTANEOUS RHEOLYTIC THROMBECTOMY

• Koning et al. (Circulation 1997) - Successful
  thrombectomy in 2 patients with severe
  symptomatic pulmonary embolism and
  contraindications to thrombolytics.
• Voigtlander et al. (Cath Card Interv 1999) -
  Successful thrombectomy in 3/5 patients with
  massive pulmonary embolism and contraindications
  to thrombolytics.

72
PERCUTANEOUS THROMBECTOMY

• PATIENT 1
• 72 Y/O MAN WITH TIA. DYSPNEA/ NEAR-SYNCOPE
• TEE THROMBUS IN RIGHT INFERIOR PA
• PULMONARY ANGIOGRAM CONFIRMED
• CT SCAN BRAIN HEMORRHAGIC INFARCT
• PERCUTANEOUS THROMBECTOMY WITH EXCELLENT
  IMMEDIATE RESULT
• DISCHARGED. 1 MO F/U FREE OF THROMBUS

Koning,R et al.Circulation 1997962498-500
73
PERCUTANEOUS THROMBECTOMY

• PATIENT 2
• 74 Y/O MAN, TRAUMA, FX TIBIA
• HD 9 RIGHT SIDE CHEST PAIN AND SEVERE DYSPNEA
• P.E., ECG, CXR SUGGESTIVE OF PE
• PULMONARY ANGIOGRAM MASSIVE BILATERAL EMBOLISM
• PERCUTANEOUS THROMBECTOMY TO LLL
• DISCHARGED. 1 MO F/U NO THROMBUS LLL.

Koning,R et al.Circulation 1997962498-500
74
PATIENT CHARACTERISTICS
PATIENT AGE GENDER CLINICAL STATUS
CONTRAINDICATION 1 25
M ORTHOPNEA, LOW BP SKULL
INJURY 2 70 M
CARDIOGENIC SHOCK RECENT SURGERY 3
72 M CARDIOGENIC
SHOCK CRITICAL BLEEDING 4
72 M ORTHOPNEA, LOW BP
ACTIVE ULCER 5 52 F
CARDIOGENIC SHOCK SURGERY 14 D AGO
Voigtlander et al. Cath Card Interv. 4791-96
1999
75
CLINICAL RESULTS

• Patients 1,2,3 successfully treated Pt 2 died on
  day 12 of cerebral hemorrhage
• Patients 4,5 underwent surgical thrombectomy
• 3-month follow-up (Pts 1,3,4,5) normalized RV
  function and asymptomatic
• Patients 4,5 histological analysis revealed
  organized thrombi with partial fibrosis

Voigtlander et al. Cath Card Interv. 4791-96 1999
76
ANGIOGRAPHIC RESULTS
TOTAL MILLER SCORE INVOLVEMENT
REDUCTION OF FLOW
(X/34)
(X/16) (X/18)
Voigtlander et al. Cath Card Interv.4791-96 1999
77
HEMODYNAMIC RESULTS
Voigtlander et al. Cath Card Interv.4791-96 1999
78
THROMBECTOMY LIMITATIONS

• RISK OF MECHANICAL PERFORATION ?
• AGE OF THROMBUS
• Rate of thrombolysis depends on the age of
  thrombus

ORGANIZED THROMBUS
LYSIS RATE 5 MG/ SEC NONORGANIZED THROMBUS
LYSIS RATE 70 MG/ SEC
ANEMIA
Stahr P et al. Z Kardiol 1997 86 (suppl 2) 289
79
EMERGENT SURGICAL EMBOLECTOMY

• Operative mortality rate 30-40
• Independent predictors of mortality
  Cardiac arrest assoc. cardiopulmonary disease
• Major causes of mortality incomplete thrombus
  removal with persistent RV dysfunction, and
  severe reperfusion lung injury
• Consider as primary therapy in PE gt 14 days old

80
EMERGENT SURGICAL EMBOLECTOMY
Recent series 29 patients treated by a
dedicated team 24 hour availability Emergency
transport Surgical technique without aortic
crossclamp or cardioplegia IVC Filters in all
patients Moderate/severe RV dysfunction with
extensive PE No antecedent CPR 11 1-month
mortality (89 survival 26/29 patients)
Aklog, Circulation 2002
81
THROMBOENDARTERECTOMY HEMODYNAMIC VALUES
PREOP POSTOP 3 moFOLLOW-UP
Moser et al. Circulation 81 1735,1990
82
PREVENTION

• In medical ICU, DVT develops in one third of
  patients half of these involved the proximal
  portion of the leg.
• Choose most adequate prophylactic method
• Keep high index of suspicion, especially in
  high-risk patients

Hirsch et al. JAMA 1995274335-7
83
SUMMARY

• Pulmonary embolism manifests in spectral fashion,
  and management (diagnostic and therapeutic) may
  be just as varied and nonuniform due to options
  available.

84
SUMMARY

• Echocardiography is a useful tool for
  risk-stratification of stable patients who
  otherwise might benefit from a more aggressive
  approach.
• Echocardiographic evidence of RV Dysfunction adds
  weight to a clinical suspicion of PE in an
  unstable patient unable to undergo further
  testing, therefore, expedites therapeutics.

85
SUMMARY

• The optimum application of thrombolytic therapy
  remains in doubt. Some authorities argue for
  treatment of only unstable patients, while others
  would enlarge indications to include those with
  echo or CT evidence of RV Dysfunction.

86
SUMMARY

• A catheter-based approach seems feasible and safe
  as primary therapy for massive pulmonary embolism
  in acute cases (lt 14 days old) when thrombolysis
  is contraindicated or unsuccessful.
• Surgical embolectomy may be a better option for
  older clots (gt 14 days old).

87
SUMMARY

• Further studies are needed to answer the
  questions regarding effectivenes and clinical
  benefit of the catheter-based approach and
  emergency thrombectomy compared to thrombolytics.

88
Protocol for the Treatment of Massive Pulmonary
Embolism in Patients Who Have Contraindications
to Thrombolytic Therapy using the Possis AngioJet
System
89
Inclusion / Exclusion Criteria

• Inclusion
• Symptomatic massive PE
• RV Dysfunction
• Contraindications to thrombolysis
• Recent PE lt 14 days
• Age gt 18

• Exclusion
• Severe Anemia
• Inability to tolerate hemolysis
• Chronic terminal illness
• PE gt 14 days
• Inability to obtain informed consent or follow up

90
Procedure

• Establish Diagnosis
• Diagnostic Studies
• VQ Lung Scan
• Spiral CT
• Echocardiogram for RV Function
• Pulmonary Angiography
• Rheolytic Thrombectomy
• Follow Up 24 hours, at hospital D/C and 30 days

91
Protocol for the Treatment of Patients with
Normotensive Submassive Pulmonary Embolism with
Right Ventricular Dysfunction

• Randomize Patients
• Standard Care (anticoagulation) vs. Lytic Therapy
• Subgroup patients with contraindications or high
  risk for bleeding with thrombolytics can be
  treated with AngioJet
• Exclude patients with chronic terminal illness
• Follow Up Assessment
• Cardiopulmonary Treadmill Testing
• VQ Lung Scan

92
Protocol for the Treatment of Patients with
Normotensive Submassive Pulmonary Embolism with
Right Ventricular DysfunctionFollow-up
Assessment and End-points

• 30 day mortality
• Bleeding complications
• Thrombolytic dose and cost
• Echo
• V/Q lung scan
• Cardiopulmonary Stress test

93
Contemporary Management of Pulmonary Embolism

• Lowell I. Gerber M.D.