Brief Article
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World J Cardiol. May 26, 2013; 5(5): 141-147
Published online May 26, 2013. doi: 10.4330/wjc.v5.i5.141
Mechanical breakdown and thrombolysis in subacute massive pulmonary embolism: A prospective trial
Bishav Mohan, Shibba Takkar Chhabra, Naved Aslam, Gurpreet Singh Wander, Naresh Kumar Sood, Sumati Verma, Anil Kumar Mehra, Sarit Sharma
Bishav Mohan, Shibba Takkar Chhabra, Naved Aslam, Gurpreet Singh Wander, Naresh Kumar Sood, Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Ludhiana141001, Punjab, India
Sumati Verma, Dayanand Medical College and Hospital, Ludhiana 141001, Punjab, India
Anil Kumar Mehra, Department of Medicine, Keck School of Medicine, LAC-USC Medical Center, Los Angeles, CA 90033, United States
Sarit Sharma, Department of Social and Preventive Medicine, Dayanand Medical College and Hospital, Ludhiana 141001, Punjab, India
Author contributions: Mohan B conceived the idea and performed mechanical breakdown and thrombolysis in these patients and guided the project; Chhabra ST involved in case selection, data analysis, procedural assistant and review of literature initially as a fellow in cardiology and then as assistant professor during the follow up phase; Verma S involved in case selection and review of literature as a medical intern; Sharma S involved in statistical analysis of data as an associate professor in department of social and preventive medicine; Aslam N, Sood NK and Wander GS associated team of interventional cardiologists who were actively involved in assisting the procedures and supervised the study; Mehra AK visited interventional cardiologist who assisted the cases and guided data analysis and the completion of the project.
Correspondence to: Bishav Mohan, Professor, Department of Cardiology, Dayanand Medical College and Hospital, Unit Hero DMC Heart Institute, Tagore Nagar, Civil Lines, Ludhiana 141001, Punjab, India. bishav_68@yahoo.co.in
Telephone: +91-161-203428287-381 Fax: +91-161-2309595
Received: February 11, 2013
Revised: April 24, 2013
Accepted: May 8, 2013
Published online: May 26, 2013
Processing time: 103 Days and 7.3 Hours
Abstract

AIM: To assess role of combined modality of mechanical fragmentation and intralesional thrombolysis in patients with massive pulmonary embolism presenting subacutely.

METHODS: Eight of 70 patients presenting in tertiary care centre of North India with massive pulmonary embolism within 4 years had subacute presentation (symptom onset more than 2 wk). These patients were subjected to pulmonary angiography with intention to treat basis via mechanical breakdown and intra lesional thrombolysis. Mechanical breakdown of embolus was accomplished with 5-F multipurpose catheter to re-establish flow, followed by intralesional infusion of urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h).

RESULTS: Eight patients, mean age 47.77 ± 12.20 years presented with subacute pulmonary embolism (mean duration of symptoms 2.4 wk). At presentation, mean heart rate, shock index, miller score and mean pulmonary pressures were 101.5 ± 15.2/min, 0.995 ± 0.156, 23.87 ± 3.76 and 37.62 ± 6.67 mmHg which reduced to 91.5 ± 12.2/min (P = 0.0325), 0.789 ± 0.139 (P = 0.0019), 5.87 ± 1.73 (P = 0.0000004) and 27.75 ± 8.66 mmHg (P = 0.0003) post procedurally. Mean BP improved from 80.00 ± 3.09 mmHg to 90.58 ± 9.13 mmHg (P = 0.0100) post procedurally. Minor complications in the form of local hematoma-minor hematoma in 1 (12.5%), and pseudoaneurysm (due to femoral artery puncture) in 1 (12.5 %) patient were seen. At 30 d and 6 mo follow up survival rate was 100% and all the patients were asymptomatic and in New York Heart Association class 1.

CONCLUSION: Combined modality of mechanical fragmentation and intralesional thrombolysis appears to be a promising alternative to high risk surgical procedures in patients with subacute massive pulmonary embolism.

Keywords: Mechanical breakdown; Subacute; Thrombolysis; Thromboembolic; Intra pulmonary; Catheter directed

Core tip: Patients with massive pulmonary embolism presenting subacutely (> 2 wk) have high mortality and older clots in these patients may be less amenable to thrombolysis with increased likelihood of recurrence and thromboembolic pulmonary hypertension. Eight of 70 patients with massive pulmonary embolism presenting subacutely were subjected to mechanical breakdown and intra lesional thrombolysis with urokinase (4400 IU/kg over 10 min followed by 4400 IU/kg per hour over 24 h). Post procedurally, patients documented significant improvement in hemodynamic parameters with 100% survival at 30 d and 6 mo followup. This modality appears to be a promising alternative to high risk surgical procedures in such patients.