Saddle vs Nonsaddle Pulmonary Embolism: Clinical Presentation, Hemodynamics, Management, and Outcomes

Alkinj, Bashar; Pannu, Bibek S.; Apala, Dinesh Reddy; Kotecha, Aditya; Kashyap, Rahul; Iyer, Vivek N.

doi:10.1016/j.mayocp.2017.07.014

Cited by 20 publications

(24 citation statements)

References 23 publications

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“…Although difficult to compare across retrospective studies, inhospital mortality rates of previous studies (0–4.3%) were half of what was found in our study, but most of these studies had smaller sample size ( 5 – 9 ). Only one previous study had a sample size greater than 40 ( 5 ), but this study of 180 patients also had a lower inhospital mortality rate (4.3%) in patients diagnosed with SPE. The difference in mortality rates may be due to the different racial characteristics and associated comorbidities of the patient populations.…”

Section: Discussioncontrasting

confidence: 72%

“…Although one retrospective study showed worse 1-year overall mortality of SPE versus central PE in cancer patients (83.3% vs 41.2%) ( 7 ), other studies have shown an inhospital mortality that was not statistically different from matched non-SPE ( 5 – 9 ). These prior studies were limited by low sample sizes with only one study having more than 50 patients with SPE ( 5 ). This present study aims to characterize the presentation, diagnosis, management, and outcomes of 120 patients with SPE.…”

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confidence: 96%

“…For non-SPE, death attributed to PE has been reported in the range of 1–7.0% ( 2 – 4 ). SPE occurs in approximately 2.6–5.4% of all acute PE cases and has been thought to portend poorer outcomes without aggressive treatment ( 5 , 6 ). Treatment options range from standard anticoagulation (AC), systemic thrombolysis, catheter-directed thrombolysis, and surgical embolectomy ( 6 ).…”

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confidence: 99%

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Saddle Pulmonary Embolism: Demographics, Clinical Presentation, and Outcomes

Wong

Kushnir

Billett

2021

Critical Care Explorations

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OBJECTIVES: Saddle pulmonary embolism is an uncommon type of venous thromboembolism that can lead to sudden hemodynamic collapse and death. Saddle pulmonary embolism can be difficult to recognize, and data on its presentation, clinical features, and associated complications are sparse. We sought to characterize patients with saddle pulmonary embolism. DESIGN: The Montage software (Nuance, Burlington, MA) was used to identify patients to create a retrospective cohort study. SETTING: Montefiore Medical Center from January 1, 2012, to December 31, 2018. PATIENTS: All subjects diagnosed with saddle pulmonary embolism in above time period. INTERVENTIONS: Charts were reviewed for demographics, diagnostics, laboratory data, presenting vital signs, inhospital mortality, 6-month survival, and prevalence of recurrent venous thromboembolism. MEASUREMENTS AND MAIN RESULTS: About 120 patients with saddle pulmonary embolism were identified. Median age was 61 years and 57.5% were women. Events were provoked by a transient risk factor in 43.3%. On presentation, median mean arterial pressures were normal (93 mm Hg). Only five of 120 of patients (4.2%) presented with vitals concerning for massive pulmonary embolism. We found a 9.2% inhospital mortality; an additional 8.6% died within 6 months of discharge. Inhospital mortality was higher in women (11.6%), compared with men (3.9%), but this was not significant ( p = 0.28). In 10 patients, both ventilation/perfusion scans and computed tomography pulmonary angiogram were performed. None of the ventilation/perfusion scans diagnosed saddle pulmonary embolism. Thrombus was visualized in the right heart in eight of 105 (7.6%), and this group had a higher inhospital mortality (37.5%). Recurrent venous thromboembolism occurred in 13 of 85 of survivors (15.3%). CONCLUSIONS: Despite presenting without the accepted clinical criteria for massive pulmonary embolism, saddle pulmonary embolism has a very high inhospital mortality. Ventilation/perfusion scan is unable to diagnose saddle pulmonary embolism. Visualized right heart thrombi portend an even higher inhospital mortality.

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Section: Discussioncontrasting

confidence: 72%

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confidence: 96%

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confidence: 99%

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Saddle Pulmonary Embolism: Demographics, Clinical Presentation, and Outcomes

Wong

Kushnir

Billett

2021

Critical Care Explorations

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“…Central arteries are most commonly involved 3 . The saddle PE, a thrombus straddling the bifurcation of the main pulmonary artery trunk, is found in 2–5% of all patients with PE 4 and the short-term mortality in such patients is estimated at 4.3%, while the overall risk of death in all PE cases is estimated at 5.4% 5 . Factors that determine the location of embolic material in PE are largely unknown.…”

Section: Introductionmentioning

confidence: 99%

Faster fibrin clot degradation characterizes patients with central pulmonary embolism at a low risk of recurrent peripheral embolism

Kupis

Goldman‐Mazur

Polak

et al. 2019

Sci Rep

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It is unclear whether thrombus location in pulmonary arteries is associated with particular clot characteristics. We assessed 156 patients following either central or peripheral pulmonary embolism (PE). Plasma clot lysis time, the rate of D-dimer release from plasma clots (D-Drate) with the maximum D-dimer concentration achieved (D-Dmax), as well as fibrin formation on turbidimetry, plasma clot permeation, thrombin generation, and fibrinolytic parameters were measured 3–6 months after PE. Patients following central PE (n = 108, 69.3%) were more likely smokers (38.9% vs 18.8%; p = 0.01), less likely carriers of factor XIII Val34Leu allele (40.7% vs 62.5%, p = 0.01), exhibited 16.7% higher D-Drate and 12.7% higher tissue plasminogen activator antigen (tPA:Ag) compared with peripheral PE (p = 0.02 and p < 0.0001, respectively). Saddle PE patients (n = 31, 19.9%) had 11.1% higher D-Drate and 7.3% higher D-Dmax compared with central PE (both p < 0.05). Twenty-three recurrent PE episodes, including 15 central episodes, during a median follow-up of 52.5 months were recorded. Plasma D-dimer and tPA:Ag were independent predictors for central recurrent PE, whereas D-Drate and peak thrombin predicted peripheral recurrent PE. Plasma clots degradation is faster in patients following central PE compared with peripheral PE and fibrinolysis markers might help to predict a type of recurrent PE.

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“…Computed tomography angiogram is the diagnostic imaging test of choice, but a nuclear medicine ventilation perfusion scan may also be utilized [2]. A saddle PE, now more commonly termed a massive PE is a VTE so large that it straddles the primary pulmonary arterial trunk at the bifurcation which then causes strain on the right side of the heart [3].…”

Section: Discussionmentioning

confidence: 99%