International Society For Minimally Invasive Cardiothoracic Surgery

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Low Dose Ultrasound Accelerated Thrombolysis In Early Postoperative Massive Pulmonary Embolism
Nima Hatam, FASE FETCS, Konstantina Spetsotaki, Henning Steffen, Rachad Zayat, Jan Spillner.
University Hospital RWTH Aachen, Aachen, Germany.

Background: Therapy of severe pulmonary embolism (PE) in patients immediately after surgery poses a difficult challenge with regards to bleeding complications. Ultrasound accelerated thrombolysis (USAT) has proven to be an effective therapy for severe PE using a fraction of conventional lysis doses. In this case series we present 3 cases with severe PE immediately after surgery treated by ultra low-dose USAT. Methods: Between June and October 2017 3 patients (2 male, 60 & 61 years old; 1 female, 16 years old) with symptomatic massive PE early after surgery were presented to our interdisciplinary PE response team where ultra low-dose USAT was decided to be applied due to the extent of PE and previous surgery in all patients. The patients were fitted with 2 EKOS® 12 cm devices (BTG Ltd, Surrey, UK) in each respective pulmonary artery across the occlusive thrombi for 6 hours receiving 1 mg rt-PA/h/catheter. Transthoracic echograms and CT-scans were performed before and within 48 hours of therapy initiation. Results: All 3 patients survived USAT uneventful with minor bleeding receiving a total dose of 12 mg rt-PA per patient. Within the first hours of therapy significant reduction of RV/LV ratio (1.3±0.2 vs. 0.7±0.08, p: 0.043) and mean pulmonary arterial pressure (MPAP, 33.4±6.1 mmHg vs. 21.7±3.2 mmHg, p: 0.021) as well as significant increase of oxygen saturation on room air (O2 sat, 83.6 ± 4.1 vs. 99.3 ± 1.1, p: 0.012) and right ventricular peak systolic strain rate (RV STR, -1.12±0.07 s−1 vs. -1.37±0.05 s−1, p: 0.011) was observed. Notable reduction of heart rate, systolic pulmonary arterial pressure and longitudinal peak systolic strain (RV ST) and an increase in tricuspid annular plane systolic excursion (TAPSE) and tricuspid annular systolic velocity (TASV) were also documented (see table). Follow-up CT scans revealed only minor remaining non-obstructive thrombi. Conclusion: In this case series, ultra- low-dose USAT resulted in nearly complete resolution of thrombus within 6 hours of therapy with very rapid recovery of hemodynamics in these highly symptomatic patients. Thus, ultra- low-dose USAT appears to be a safe and reasonable therapy option for early postoperative PE.

Hemodynamic and echocardiographic data
Baseline48 hp-values
Heart rate {s−1}125 ± 1778 ± 110.103
TAPSE {mm}14.5 ± 3.821.5 ± 4.00.146
TASV {cm/s}7.5 ± 2.115.8 ± 2.30.071
RV/LV ratio1.3 ± 0.20.7 ± 0.080.043
RV ST {%}-13.8 ± 3.5-20.6 ± 2.90.117
RV STR {s−1}-1.12 ± 0.07-1.37 ± 0.050.011
SPAP {mmHg}47.3 ± 10.831.7 ± 11.50.060
MPAP {mmHg}33.4 ± 6.121.7 ± 3.20.021
O2 sat. {%}83.6 ± 4.199.3 ± 1.10.012

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