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THE EVALUATION OF THE THROMBOLYTIC THERAPY IN MAJOR PULMONARY EMBOLISM

THE EVALUATION OF THE THROMBOLYTIC THERAPY IN MAJOR PULMONARY EMBOLISM. Selda Kaya 1 , Ayşegül Karalezli 1 , H. Canan Hasanoğlu 1 , Ekrem Yeter 2 1. Pulmonary Diseases, Ankara Ataturk Training and Research Hospital, 2. Cardiology, Ankara Ataturk Training and Research Hospital,. Introduction.

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THE EVALUATION OF THE THROMBOLYTIC THERAPY IN MAJOR PULMONARY EMBOLISM

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  1. THE EVALUATION OF THE THROMBOLYTIC THERAPY IN MAJOR PULMONARY EMBOLISM Selda Kaya1, Ayşegül Karalezli1, H. Canan Hasanoğlu1, Ekrem Yeter 2 1. Pulmonary Diseases, Ankara Ataturk Training and Research Hospital, 2. Cardiology, Ankara Ataturk Training and Research Hospital,

  2. Introduction Major pulmonary embolism is one of the most important issues of respiratory emergencies because of its high mortality. Recently it is still controversial to apply thrombolytic therapy to patients with massive embolism and hemodynamically stable submassive ones with cardiac findings on echocardiography.

  3. Introduction The aim of this study were to evaluate the clinical efficacy and safety of thrombolytic therapy in patients diagnosed as major pulmonary embolism

  4. Patients and method In our department we evaluated 33 patients who had the diagnosis of major pulmonary embolism via clinical symptoms, echocardiography and computerized tomography. While 17 patients ( group 1) were given tissue plasminogen activator (r- TPA) 100 U/ L in two hours at ICU, the others ( group 2) were given heparin. Clinical and laboratory findings were compared.

  5. Patients and method • Symptoms and signs , predisposing factors, blood gas analysis, the level of D- dimer, the findings of ECG,ECHO, CT-Angiography and Doppler USG,treatments, side effects and complications were all recorded for our study population consisting of patients 18 years of age or older.

  6. Patients and method Diagnostic criteria for massive embolism: • Obstruction in at least % 50 of pulmonary vascular bed or two and more lobar arteries in spiral CT angiography • Spiral CT angiography findings + cardiogenic shock and/or arterial hypotension *Arterial hypotension is defined as systolic blood pressure <90 mmHg or a pressure drop at least 40 mmHg for a time period > 15 min, if not due to new onset arrhythmia, hypovolemia or sepsis.

  7. Patients and method Submassive embolism is defined as (*): • Thrombus in at least one segmental pulmonary artery in spiral CT angiography, which can not be defined as massive . • Two- dimensional and Doppler echocardiographic findings indicating acute right ventricular pressure overload ( right atrial or ventricular dilatation, paradoxical septal motion, or pulmonary arterial hypertension), thrombus in the right heart or pulmonary arteries in the absence of left ventricular or mitral valve disease. (*)Hemodynamic parameters were stable in this group

  8. Patients and method • The patients who had no contraindications for thrombolytics were given r-TPA 100 U/ L in two hours at ICU and they were monitorized for vital signs,blood gas analysis and side effects (group 1). • Patients who had contradications for thrombolytics were given heparin (group 2).

  9. Contraindications of r-TPA • Recent (within 2 months) cerebrovascular accident, or intracranial or intraspinal surgery • Active intracranial disease( aneurysm, vascular malformation, neoplasm) • Major internal bleeding,within the past 6 months • Uncontrolled hypertension( systolic blood pressure ≥ 200 or diastolic blood pressure ≥ 110) • Bleeding diathesis, including that associated with renal or hepatic disease • Recent (< 10 days) major surgery, puncture of a noncompressible vessel, organ, or obstetric delivery • Recent need for CPR because of major/minor trauma • Infective endocarditis • Pregnancy • Hemorrhagic retinopathy • Pericarditis • Aneurysm Arcasoy SM, Kreit JW. Chest 1999; 115: 1695- 707

  10. Recording of the findings • Symptoms and signs  pretreatment and in 24 hours • Blood gase analysis pretreatment and in 24 hours • Systolic pulmonary artery pressure measurement  pretreatment and on the 7th day • The level of D- dimer pretreatment and on the 3rd days( the cut- off level is 500ng/L,by ELISA) • Data processing and analysis were performed with SPSS program version 11.0. Categorical data analyses were done by Fisher exact test

  11. Results • The mean age of the group of 1 was 55.64 ±12 (6 men, 11women) • The mean age of the group of 2 was 61.18±15 (5 men, 11 women) • There were no statistically significant difference between the age of groups.

  12. Predisposing factors

  13. Results- diagnosis -The positive findings of the lower extremity Doppler USG: Group 1  5 Group 2  3 -The mean pressure of the Pulmonary arteries (pre- and postreatment ): Group182/ 36 mm Hg Grup252/ 34 mm Hg

  14. Results- diagnosis- CT angiography findings

  15. Results- Group 1

  16. Results- Group 2

  17. Differences between the groups

  18. Differences between the groups

  19. Findings of ECHOCARDIOGRAPHY, ECG • There was statistically significant difference between mean pulmonary pressure levels among each group before and after treatments. • Mean pulmonary pressure of group 1 was significantly higher than group 2 before and after the therapy ( p< 0,005). • In echocardiographic evaluation, right heart dilatation turned to normal in 6 of 16 patients in Group 1 and 4 of 11 patients in Group 2. • Thrombus in right heart were detected by echocardiography in 3 of 17 patients in Group 1. All of them disappeared by thrombolytic therapy after 1 week • For both groups, ECG findings turned to normal significantly after the therapy ( p ≤ 0.04), but no significant differences between the groups were observed.

  20. Side effects( Group 1)

  21. Discussion • The role of CT-Angiogrpahy and ECHO in the diagnosis of major embolism is important. It is supportive to clinican for determinating of pathologic extensive and treatment choice. • In case of sudden hypotension and changes in blood gases, its ability in rapid diagnosis, makes transthoracic ECHO important.The detection of intracardiac thrombus which increase mortality and monitiorization of patient during thrombolytic treatment can also be achieved by ECHO.

  22. Discussion The trombolytic therapy can be prefered because of more rapid symptom control. But it must be applied in ICU because of monitorization of side effects and rapid intervention. In some cases with submassive embolisms, thrombolytic treatment can be suggested especially without of improvement in saturation and hemodynamic parameters

  23. Conclusions Our study shows that, thrombolytic therapy can be safely used for the treatment of major thromboembolism. But studies with larger patient populations are needed on this subject.

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