Comparative efficacy of different modalities for treatment of right heart thrombi in transit: A pooled analysis

Abstract

The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Early surgical treatment in patients with pulmonary embolism and thrombus-in-transit

“…However, thrombolytic therapy is not warranted in most cases in abscense of hypotension (5,(12)(13)(14). Few studies, only case series and retrospective studies, have compared thrombolysis with surgical therapy in acute PE and recommended to consider surgical pulmonary embolectomy in case of hypotension and contraindication for thrombolysis or life-threatening situations like failure of thrombolysis, RV failure, cardiogenic shock and TT (3,12,15,16). According to current European Society of Cardiology guidelines, in patients with TT, the therapeutic benefits of thrombolysis remain controversial (16).…”

“…Optimal treatment for acute PE and concomitant TT is not defined currently due to the absence of randomized controlled trials and it must be considered on a case-by-case basis by multidisciplinary teams after a risk-benefit assessment (4)(5)(6)16). Patients receiving no therapy had a 90-100% mortality rate (2,3,8). Furthermore, mortality rate is high (8,9) (21.1%) (2) within the first 24 hours, which warrants an immediate treatment (3,16).…”

“…Patients receiving no therapy had a 90-100% mortality rate (2,3,8). Furthermore, mortality rate is high (8,9) (21.1%) (2) within the first 24 hours, which warrants an immediate treatment (3,16). Thus, inotropic support with catecholamine infusion should be prepared immediately after the diagnosis of TT and administered as soon as either the patient's BP falls below 100 mmHg or cardiogenic shock is suspected.…”

“…Different therapeutic approaches have been reported for acute PE with concomitant TT: anticoagulation with UFH, systemic thrombolysis with recombinant tissue plasminogen activator (rTPA), surgical embolectomy with exploration of the right chambers and the pulmonary arteries under full cardiopulmonary bypass, and endovascular thrombectomy (1,5). Systemic thrombolysis and surgical embolectomy showed a higher probability of survival (81.5% and 70.45% respectively) in comparison with anticoagulation (47.7%) (2,3,8). Nevertheless, there are contradictory data regarding the TT management; a recent study that included patients with acute PE associated with TT from the RIETE registry showed that there were no significant differences for mortality and bleeding between reperfusion therapy (i.e., thrombolysis, surgery) and anticoagulation (7).…”

“…It is, therefore, a serious manifestation of VTE and with very high frequency (more than 90%) is associated with deep vein thrombosis (DVT) or pulmonary embolism (PE) (1). Given the high mortality rate without treatment (90%) and being largely precocious (in the first 24 hours), close monitoring in critical units and urgent treatment are warranted (including systemic fibrinolysis or surgical embolectomy in addition to conventional anticoagulation) (2,3). TT is an uncommon manifestation of symptomatic PE, with an approximate frequency of 4%…”